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Full text of "Dental infections, oral and systemic"

West Virginia University Libraries 



3 0802 102296250 1 



ihiVi/i H .'W I :,l K . BlMri 4 !iTI ' I •! I V 



DENTAL INFECTIONS 

O HA L AN D SYSTEM IC 



WESTON- A- PRICE 



DO NOT CIRCULATE 



4 




Volume I 

RESEARCHES ON ORAL AND SYSTEMIC EXPRESSIONS 
OF DENTAL INFECTIONS 




ACUTE PULPITIS. 

Symptoms — Hypersensitiveness to thermal change. Histopathology — Interstitial 

hemorrhage into dental pulp from infected caries. 

Frontispiece Vol. I. 



DENTAL INFECTIONS 

ORAL AND SYSTEMIC 



(Volume I ) 



BEING A CONTRIBUTION TO THE PATHOLOGY OF DENTAL INFECTIONS 
FOCAL INFECTIONS, AND THE DEGENERATIVE DISEASES 



By 

WESTON A. PRICE, D. D. S., M. S., F. A. C. D. 

Specialist in Dental Research and the Diagnosis, Prognosis, and Treatment of Dental Infections. 

Chairman Research Section of The American Dental Association, 1914 to present. 

Organizer of The Research Commission of The American Dental 

Association. Organizer of The Research Institute of 

The American Dental Association 

(Discontinued) 

this is the experimental basis for volume ii 
"Dental Infections and the Degenerative Diseases" 

Volume I Presents 

Researches on Fundamentals of Oral and Systemic 
Expressions of Dental Infections 

Volume II Presents 

Researches on Clinical Expressions 
of Dental Infections 



From the Author's Private Research Laboratories 
8926 Euclid Avenue, Cleveland, Ohio 



THE PENTON PUBLISHING COMPANY 

Scientific Publishers 

PENTON BUILDING CLEVELAND, OHIO 



LSBFU 
RENTAL GHOUL 



i 



Copyrighted 1923 

WESTON A. PRICE, D. D. S., M. S., F. A. C. D. 

CLEVELAND. OHIO 
(Printed in the United States of America) 



Printed by 

THE PENTOS PRESS CO. 

Cleveland 



r 



Mr. and Mrs. Francis E. Drury 

MY ESTEEMED FRIENDS 

In Appreciation of 

Their Kindly Encouragement and Helpful Interest 

This Volume is Affectionately Dedicated 



A New Truth a New Sense 



THE acquisition of a new truth is like the 
acquisition of a new sense, which renders a 
man capable of perceiving and recognizing a 
large number of phenomena that are invisible 
and hidden from another, as they were from 
him originally." LlEBlG. Chemische Briefe 



TABLE OF CONTENTS VOLUME I 

INTRODUCTION. 

CHAPTER I 

Page 
CAPABILITIES AND LIMITATIONS OF THE 
ROENTGEN-RAYS . 35 

Problem: To what extent are the Roentgen-rays capable of 
disclosing dental infections? 

CHAPTER II 

THE NATURE OF THE ORGANISMS INVOLVED . 55 

Problem: Is the danger from a dental infection primarily 
dependent upon the invasive quality of the organisms in- 
volved: or, otherwise stated, is it true that dental infections, 
w hen I hey occur at the apices of roots, are produced by the 
invasion of that area by organisms from the mouth which enter 
that tissue through the open pulp canal: and that the question 
of danger from such an infection is dependent upon the in- 
vasive qualities of that organism? 

(A) WHAT ARE THE MORPHOLOGICAL CHARACTER- 
ISTICS OF THE ORGANISMS? . 55 

(B) WHAT ARE THE BIOLOGICAL QUALITIES OF THE 
ORGANISMS INVOLVED? 56 

(C) WHAT IS THE RELATIONSHIP BETWEEN THE 
MORPHOLOGICAL AND BIOLOGICAL CHARACTER- 
ISTICS AND THEIR LOCAL AND SYSTEMIC TISSUE 
EXPRESSIONS? 58 

(£>) TO WHAT EXTENT ARE THE ORGANISMS INFLU- 
ENCED BY VARIATIONS IN THE PABULUM, OR 
CULTURE MEDIUM, IN WHICH THEY GROW? 59 

(E) ARE THE ORGANISMS CAPABLE OF PRODUCING 

SPECIFIC TOXIC SUBSTANCES? . 62 

CHAPTER III 

LOCAL ORAL STRUCTURAL CHANGES PRODUCED BY 

DENTAL INFECTIONS . 68 

Problem: Is there a constancy in the local oral expressions of 
similar dental infections? 

CHAPTER IV 

SYSTEMIC STRUCTURAL AND FUNCTIONAL CHANGES 

PRODUCED BY DENTAL INFECTIONS . 90 

INTERPRETATION OF RESULTS OF SUSCEPTIBILITY 

EXPERIMENTATION 92 

Problem: Are all human beings similar or sufficiently so 
that they may be considered comparable in their reactions to 
dental infections? 

VII 



VIII 

CHAPTER V PAGE 

RELATIONSHIPS BETWEEN LOCAL AND SYSTEMIC 

REACTIONS .... 109 

Problem: Is it true, as generally presumed, I hat there are no 

distinguishing characteristics which relate the type of local 

periapical reaction to the nature and extent of systemic reaction? 

CHAPTER VI 

ARE APICAL ABSORPTION AND TOOTH INFECTION 
SYNONYMOUS? 121 

Problem: Is it essentially true (a) that a tooth without visible 
absorption at its apex is not infected, and (b) that a tooth with 
visible absorption at its apex is infected? 

CHAPTER VII 
THE RELATION OF CARIES TO PULP INFECTIONS . 133 

Problem: What is the relation of the health of pulps without 
exposure to shallow and deep caries? 

CHAPTER VIII 

THE RELATION OF PERIODONTOCLASIA TO PULP 

INFECTIONS 150 

Problem: Are the pulps of teeth influenced or injured by 
periodontoclasia (pyorrhea alveolar is) unless and until that 
pathological process has mechanically severed or invaded the 
vessels entering the tooth at the root apex? 

CHAPTER IX 

THE RELATION OF DENTAL CARIES TO SYSTEMIC 

DISTURBANCE 154 

Problem: Is there a relationship between susceptibility to 
dental caries and to systemic involvements of the rheumatic 
group lesions? 

CHAPTER X 

THE RELATION OF PERIODONTOCLASIA TO SYS- 
TEMIC DISTURBANCE . . .158 
Problem: Is there a relationship between susceptibility to 
periodontoclasia (pyorrhea alveolar is) and susceptibility to 
systemic involvements of the rheumatic group lesions: or stated 
differently, is it not true that with an increase of susceptibility 
to periodontoclasia there is a marked increase in susceptibility 
to rheumatic group lesions? 

CHAPTER XI 

RELATIONSHIPS BETWEEN PERIODONTOCLASIA AND 
THE EXTENT OF PERIAPICAL ABSORPTIONS 163 

Problem: Is there a relationship between (he root end ex- 
pression of irritation and the gingival expression of irritation; 
or otherwise expressed, is there in a given case no relationship 
between the size of apical abscesses from infected roots and 
extent of periodontoclasia? 



IX 

CHAPTER XI 1 page 

THE RELATION OF THE EXTENT OF THE ABSORPTION 
TO THE DANGER 167 

Problem: Is the danger proportional to the evidence of ab- 
sorption of bone about the apex of a suspected tooth? 

CHAPTER XIII 

THE NATURE OF THE DISCHARGE FROM A DENTAL 
FISTULA . 177 

Problem: Is the discharge from a chronic dental fistula badly 
infected and eery poisonous/ 

CHAPTER XIV 

EFFICIENCY AND HARMLESSNESS OF ROOT CANAL 
MEDICATION . 184 

Problem: Can infected pulpless teeth be readily sterilized 
by root medication? 

CHAPTER XV 

ROOT FILLINGS, THEIR CONSTANCY AND EFFI- 
CIENCY . 199 

Problem: Do root fillings Jill root canals, and do they continue 
to do so? 

CHAPTER XVI 

COMFORT AND SERVICEABILITY AS SYMPTOMS . 210 

Problem: Are local comfort and efficiency of treated teeth an 
evidence and measure of the success of an operation? 

CHAPTER XVII 

QUANTITY, SYSTEMIC EFFECT, AND TOOTH CAPACITY 215 
Problem: What is the relationship of the quantity of dental 
infection to the type and extent of systemic involvement? 

CHAPTER XVIII 

STUDIES OF PULPLESS TEETH, WITH AND WITHOUT 

ROOT FILLINGS 229 

Problem: Have pulpless teeth injurious contents other than 
microorganisms? 

CHAPTER XIX 

HEMATOLOGICAL CHANGES IN THE BLOOD . 234 

Problem: What changes are produced in the blood and sera 
of the body by dental infections? 

CHAPTER XX 

CHEMICAL CHANGES IN THE BLOOD PRODUCED BY 

DENTAL INFECTIONS . ... 241 

Problem: What are the chemical changes that are produced 
in the blood bv acute and chronic dental focal infections? 



X 

CHAPTER XXI PAGE 

CONTRIBUTING OVERLOADS WHICH MODIFY DE- 
FENSIVE FACTORS 265 
Problem: What are the contributing factors causing a break 
in resistance? 



CHAPTER XXII 

ELECTIVE LOCALIZATION AND ORGAN SUSCEPTI- 
BILITY .285 
Problem: Do the organisms of dental infections possess o* 
acquire tissue affinity and elective localization qualities? 

CHAPTER XXIII 

THE ENVIRONMENT PROVIDED BY AN INFECTED 
PULPLESS TOOTH .... 311 

Problem: What are the characteristics of the habitat and 
environment furnished for bacteria in an infected pulpless 
tooth? 



CHAPTER XXIV 

ELECTIVE LOCALIZATION AND ORGAN DEFENSE . . 318 
Problem: Do diseased organs and tissues modify bacteria 
growing in the distant focus, or create in them a capacity for 
elective localization for those diseased tissues? 

PART I— INFLUENCE OF DISEASED TISSUE ON 
ORGANISMS IN THE DISTANT FOCUS 318 

PART II— NATURE OF THE DEFENSIVE MECHAN- 
ISMS .322 

CHAPTER XXV 

THE RELATION OF THE TYPE OF REACTION TO THE 
NATURE OF THE IRRITANT, BACTERIAL OR TOXIC 325 
Problem: Have we different products from dental infection? 

CHAPTER XXVI 

CHEMOTAXIS AS A MEANS FOR INCREASING DEFENSE 329 
Problem: Can defense for streptococcal infections be increased 
by introducing enterally or parenterally (by ingesting or 
injecting) chemicals? 

CHAPTER XXVII 

THE EFFECT OF RADIATION ON DENTAL PATHO- 
LOGICAL LESIONS . .... 336 
Problem: Can periodontoclasia and apical abscess and in- 
flammation be cured by various types of radiation? 



XI 

CHAPTER XXVIII page 

GINGIVAL INFECTIONS, THEIR PATHOLOGY AND SIG- 
NIFICANCE 344 

Problem: Arc the present theories regarding the etiology of 

periodontoclasia, or so-called pyorrhea alveolar is, correct' 

CHAPTER XXIX 

ETIOLOGICAL FACTORS IN DENTAL CARIES 358 

Problem: What are the dominant etiological factors in dental 



CHAPTER XXX 

THE NATURE OF SENSITIZATION REACTIONS 364 

Problem: Do dental infections produce sensitization of an 
anaphylactic character? 

CHAPTER XXXI 

PRECANCEROUS SKIN IRRITATIONS 392 

Problem: Are I here relationships between precancerous skin 
irritations and dental infections? 

CHAPTER XXXII 

RESEARCHES ON DENTAL INFECTIONS AND CARBO- 
HYDRATE METABOLISM 398 

Problem: What, if any, is the relationship between dental 
infections and carbohydrate metabolism? 

CHAPTER XXXIII 

MARASMUS ... 401 

Problem: Why do people with rheumatic group lesions tend 



to be underweight 



CHAPTER XXXIV 

PREGNANCY COMPLICATIONS ... 406 

Problem: Do dental infections have a bearing on pregnancy 
complications? 

CHAPTER XXXV 

SPIROCHETE, AMEBA, AND OTHER NON-STREP- 

TOCOCCAL INFECTIONS 409 

Problem: Do other organisms than streptococci enter the 
human system through dental infections? 

CHAPTER XXXYI 

NUTRITION AND RESISTANCE TO INFECTION . 416 

Problem: Does faulty nutrition, through a deficiency diet, 
decrease the defense against dental infections? 



XII 



CHAPTER XXXVII 



Page 



THE RELATION OF THE GLANDS OF INTERNAL SE- 
CRETION TO DENTAL INFECTIONS AND DEVELOP- 
MENTAL PROCESSES 421 

Problem: To what extent are the glands of internal secretion 
related to dental injections and to dental developmental pro- 
cesses? 

(1) THE CORRECTION OF DISTURBANCES AND 
DISFUNCTIONS OF THE GLANDS OF INTERNAL 
SECRETION OF THE PATIENTS BY THE REMOVAL 

OF THEIR DENTAL INFECTIONS . . .421 

(2) THE PRODUCTION OF DISTURBANCES IN THE 
GLANDS OF INTERNAL SECRETION OF ANIMALS 
BY THE INJECTION INTO THEIR CIRCULATION OF 
CULTURES TAKEN FROM TEETH OF INVOLVED 
PATIENTS ... 427 

(3) THE MODIFICATIONS OF THE PATIENTS' SYS- 
TEMIC INVOLVEMENTS FROM DENTAL INFEC- 
TIONS BY THE ADMINISTRATION OF EXTRACTS 

OF THESE GLANDS .... 431 

(4) THE IMPROVEMENT OF THE FUNCTIONING OF 
THE GLANDS OF INTERNAL SECRETION BY THE 
MECHANICAL STIMULATION INDUCED BY THE 
MOVEMENT OF THE BONES OF THE FACE AND 
BASE OF THE SKULL 435 



CHAPTER XXXVIII 

THE NATURE AND FUNCTION OF THE DENTAL 

GRANULOMA 442 

Problem: Is a dental granuloma a pus sac and its size a 
measure of the infection and danger? 



CHAPTER XXXIX 

CHANGES IN THE SUPPORTING STRUCTURES OF THE 
TEETH, DUE TO INFECTION AND IRRITATION 
PROCESSES .... . . .470 

Problem: What are the changes produced in the supporting 
structures of the teeth, which are due to infection and irrita- 
tion processes? 



CHAPTER XL 

DENTAL INVOLVEMENTS CAUSED BY ARTHRITIS . 486 

Problem: Can arthritic infections of the body attack and 
devitalize the teeth? 



XIII 

CHAPTER XL! Pag , 

(A) VARIATIONS IN THE DEFENSIVE FACTORS OF 

11 IK BLOOD 501 

Problem: Is there a difference in the defensive factors of tin 
blood of susceptible and non-susceptible individuals to systemic 
involvements from dental infections? 

(B) SEROPHYTIC MICROORGANISMS 519 

Problem: What arc the growth factors of microorganisms of 
the mouth in juices of living tissius? 

CHAPTER XLII 

METHODS FOR REINFORCING A DEFICIENT DEFENSE 526 

Problem: Can a temporarily or permanently low defense 
against the streptococci of dental infections be increased or en- 
hanced either temporarily or permanently? 

MEANS FOR COMPARING AND CLASSIFYING THE 

DEFENSIVE FACTORS OF PATIENT'S BLOOD . 529 

CHAPTER XLII I 

CALCIUM AND ACID- ALKALI BALANCE .540 

Problem: What is the role of calcium in the maintenance of 
the acid-alkali balance of the blood, through body fluids and 



tissues: 



CHAPTER XLIV 



DENTAL INFECTIONS AND TISSUE AND ORGAN 

DEGENERATION 555 

Problem: To what extent and in what manner do dental 
infections contribute directly or indirectly to the degeneration 
of tissues and organs of the body and to disfunction of the same? 

CHAPTER XLV 

THE LOCAL PHENOMENA OF DENTAL FOCAL INFEC- 
TION .569 

Interpretations. 

CHAPTER XLVI 
THE PHENOMENA OF LOCAL REACTION . .573 

Interpretations. 

CHAPTER XLVII 

THE PHENOMENA OF SYSTEMIC EXPRESSIONS OF - 
DENTAL INFECTIONS . . .581 

Interpretations. 

CHAPTER XLVIII 

THE PHENOMENA OF RELATIONSHIPS BETWEEN 

LOCAL AND SYSTEMIC EXPRESSIONS . 585 

Interpretations. 



XIV 

CHAPTER XLIX Page 

INHERITED SUSCEPTIBILITY AND MENDEL'S LAW . 589 
Interpretations. 

CHAPTER L 

AN INTERPRETATION OF RADIATION REACTIONS . 592 
Interpretations. 

CHAPTER LI 

THE PHENOMENA OF SENSITIZATION REACTIONS . 596 

Interpretations. 

CHAPTER LI I 

INTERPRETATION OF SEROLOGICAL STUDIES . 600 
Interpretations. 

CHAPTER LI 1 1 

THE RELATION OF GINGIVAL AND APICAL AB- 
SORPTION TO SYSTEMIC DEFENSE . 601 
Interpretations. 

CHAPTER LIV 

THE RELATION OF LOCAL TISSUE REACTION TO 

CALCIUM METABOLISM 606 

Interpretations. 

CHAPTER LV 

THE MECHANISMS OF LOCAL AND SYSTEMIC DE- 
FENSE . 610 

Interpretations. 

CHAPTER LVI 

NEW LIGHT ON THE PHENOMENA OF IMMUNITY 
AND SUSCEPTIBILITY TO DISTURBANCES FROM 
STREPTOCOCCAL INFECTIONS . 615 

Interpretations. 

CHAPTER LVI I 

GENERAL SUMMARY AND RESTATEMENT OF FUN- 
DAMENTALS 626 



LIST OF ILLUSTRATIONS VOLl'MK I i> A ,., 

1 Above: Rheumatic nodules in rabbits' feet. Below: koent- 

genographic view of same ... . . 'AG 

2 Very extensive purulent arthritis, which has extended beyond 

the joint capsules and between the muscles . 38 

3 Comparison of the apparent with the actual. A and B show, 

roentgenographically. two maxillary molars. Note their 
difference. A 1 shows the periapical granulomata attached 
to the roots of A, and B 1 the periapical granulomata at- 
tached to the roots of B. The zones of rarefaction in A 
and B are obscured by zones of condensing osteitis 39 

4 A. roentgenographic view of the root and apical area of a cus- 

pid; B, an enlargement of the root and granuloma re- 
moved from this area ..... .39 

5 Roentgenographic studies of periodontoclasia; A and B, 

different angles; C, with flexible gutta-percha points; D, 
extracted tooth. ....... 42 

6 Comparison of roentgenographic view of teeth with the photo- 

graphs of same when extracted ... .42 

7 Comparison of roentgenographic and photographic views of 

an incisor ....... .43 

8 Photographic view of external oblique ridge over second and 

third molars, which cast the shadow show in Figure 9 43 

9 Shows a radiopaque area over roots of second and third 

molars. (See Figure 8. ) . . .44 

10 A roentgenographically innocent tooth, but actually a very 

dangerous one ........ 44 

11 A comparison of the roentgenographic and photographic 

studies of teeth. Note the absence of evidence of acretions 
in the roentgenograms of the teeth in situ above, after ex- 
traction in the center, which are very clearly revealed in the 
photographs of the same after extraction, shown below . 46 

12 A, a high angle view of the upper molars; B, a low angle; C, 

the appearance of the extracted tooth . . 48 

13 Comparison of the roentgenographic and photographic ap- 

pearances of extracted teeth .49 

14 Comparison of the roentgenographic and photographic ap- 

pearances of extracted teeth ... .52 

15 Different views of the bicuspid root shown in Figure 7. A, 

side view, right angle; B, lateral view, right angle; C, lateral 
view, forty-five degrees . . .53 

16 Relation of angle of incidence of rays to tooth and film planes: 

No. 1 at right angle to plane of tooth; No. 2 at right angle 
to plane of film; No. 3 at right angle to a plane half way be- 
tween plane of film and plane of tooth, the correct position 
to make tooth appear the proper length 53 

23 A comparison of the aerobic and anaerobic growths of inocu- 
lations with a strain taken from the interior of an infected 
tooth. Aerobic, to right, completely transparent, no growth ; 
anaerobic, to left, heavv growth hiding black strip behind 
test tube 63 

25 Illustrations of different types of reactions involving apices 

of roots and their supporting structures .... 69 

XV 



XVI 

LIST OF ILLUSTRATIONS— Continued Page 

26 A degenerative arthritis of a rabbit's femur, with normal 

above ......... 70 

27 Proliferative arthritis of a rabbit's knee and joints, with 

normals to right ..... .70 

28 Proliferative deforming arthritis of patient's spine to the left. 

Proliferative deforming arthritis of rabbit's pelvic bones, 
knees, and spine, to the right ...... 72 

29 Progressive views of the bone about the second bicuspid of a 

patient with deforming arthritis over a period of twenty-two 
years. Note extensive condensing osteitis in C, displacing 
rarefying osteitis in A following treatment and refilling of 
root, which condensation disappeared after extraction. 
Tooth and bone both infected ...... 74 

30 Typical illustration of lack of reaction around several involved 

teeth . .... 74 

31 A and B show two views of an extracted molar root of the case 

shown in Figure 30, with marked excementosis fusing the 
mesial and buccal roots, and at D, the firmly attached piece 
of alveolar bone. ........ 76 

32 Shows extensive absorption of alveolar bone about all in- 

volved teeth of this individual in contrast with Figure 31 78 

33 A comparison of the type of reaction in different members of 

the same family. Note the absence of apical reaction . . 80 

34 A comparison of the type of reaction in different members of 

the same family. Note the presence of extensive apical re- 
action .......... 81 

35 Different types of reaction about adjoining teeth 82 

36 An apparent improvement in dental condition following 

break in health ....... 82 

37 Roentgenographic appearance of condensing osteitis about 

infected teeth ........ 82 

38 A group showing extensive rarefying osteitis about infected 

teeth ... 84 

39 A group showing a zone of condensing osteitis surrounding a 

zone of rarefying osteitis about infected teeth ... 86 

40 A group showing limited reaction, with or without condensing 

osteitis, about infected teeth ..... 88 

50 Typical illustrations of the local reactions in the different 

groups . . . . . .113 

5 1 Different views of an infected tooth where the roentgenographic 

evidence is negative . . . . .123 

52 A lateral abscess on the side of a bicuspid ; also apical abscess. 

(See tooth with filling. ) 124 

53 Four cases with putrescent central incisors. Condition not 

revealed roentgenographically . . .124 

54 A mandibular cuspid with apical radiolucencv below a vital 

tooth .... . .124 

55 Maxillary anesthesia . . . .126 

56 Showing zones of external anesthesia in the case of the previous 

figure .......... 126 






\\ II 

LIST OF ILLUSTRATIONS Continual p AGE 

57 Shows areas of arsenical necrosis on dog's tongue from de- 

vitalized teeth 128 

58 Shows several views of treated teeth, sonic with arsenic, 

others with formalin .128 

59 An enlarged apical medullary space resembling apical in- 

volvement ..... .128 

M ntal foramina which might be mistaken for apical in- 
volvements ......... 130 

61 Anatomical relationship of maxillary sinus and palate, suggest- 

ing apical involvement . . . 130 

62 Two views of nasopalatine foramina, easily mistaken in one 

view for apical involvement .130 

63 Thickening of peridental membrane, due to orthodontia . 130 

64 Putrescent bicuspid without apical involvement . 130 

65 Shows the peridental layer of the pulp immediately below a 

dental caries . . . .135 

66 Pulp involvement and metallic filling: B, roentgenographic; 

A. cross section of cavity and pulp; D, pulp stones; and E, 
hyperemia and fibrosis . . .136 

67 Calcifications within pulp beneath moderate caries . 137 

68 Extensive calcification in pulp of tooth of a boy fourteen 137 

69 The filling in of the pulp chamber with an osteoid bone . 139 

70 Pulp changes resulting from irritation of caries plus irritation 

of filling: C, original caries cavity in second molar; D, same 
with gold inlay; B, degeneration changes in pulp with 
fibrosis and calcification; and A, large pulp stone in coronal 
portion of pulp, not disclosed by Rosntgen-ray . . 140 

71 A zone of decalcification extending from the caries cavity 

toward the pulp. (See second molar) .... 141 

72 Sections of a tooth with deep caries, tracing changes to pulp; C, 

a cross section of tooth showing the relation of cavity to 
pulp; B, magnification of dentin showing advancement of 
decalcification following tubuli; A, a pulp nodule and 
fibrosis in pulp chamber . . ... 142 

73 An illustration of the depth of decalcification from a super- 

ficial caries; B, from the base of the caries cavity inward, 
showing the enlarged dental tubuli; A, enlargement of the 
dental tubuli, showing bacterial advancement far toward the 
pulp ......... 143 

74 Shows progressive development of infection toward the pulp 

from caries cavity under increasing enlargements in A, B, 

and C .144 

75 Shows calcification zones in pulp in A; the dentin beneath a 

leaking alloy filling in B; high powder of same in C 146 

76 Structural changes in the peridental membrane and cementum 

of tooth shown in Figures 74 and 75. A shows calcifica- 
tion in a blood vessel; B, absorption of cementum and re- 
placement with an osteoid tissue .147 

77 Shows a zone of degenerating osteoblasts beneath a zone of 

caries .......... 148 

78 Bacterial invasion and necrosis in dental pulp beneath caries . 149 



XVIII 

LIST OF ILLUSTRATIONS— Continued Page 

79 A degenerating pulp, due to periodontoclasia. A, multiple 

pulp stones, fibrosis; B, roentgenographic appearance . 151 

80 A fibrositis of the pulp, followed by calcification of same 152 

89 Food packs and gingival irritants, with different types of re- 

action .......... 161 

90 Extensive alveolar absorptions in both gingival and apical 

tissues, associated in the same individual . 164 

91 Long continued gingival and apical infection, with the re- 

sistance breaking . . ..... 164 

92 Laterals with putrescent pulps. Absent susceptibility . .168 

93 Laterals with putrescent pulps. Acquired susceptibility . 169 

94 Laterals with putrescent pulps. Mildly inherited suscepti- 

bility ... . . .170 

95 Laterals with putrescent pulps. Strongly inherited sus- 

ceptibility ....... .172 

97 Discharge from a fistula of a patient who has a high defense 178 

98 Appearance of periapical reaction of patient who has a high 

defense, referred to in Figure 97 .... . 180 

99 Smear from root apex of tooth with flowing fistula. Only phago- 

cyted organisms are seen . . .181 

100 A profuse phagocytosis from a flowing fistula . . 182 

101 Smear from apex of a tooth without a fistula . 183 

102 Changes in radiolucency about same tooth, second bicuspid, 

in fifteen years. Patient has deforming arthritis. A, taken 
in 1901; B in 1914; C in 1916. Return toward normal after 
extraction shown in D, 1920, in E, 1921, in F, 1922, and in 
G, 1923 185 

105 Three successive views of a mandibular molar. A, before 
removal of degenerating pulp; B, immediately after root 
filling; C, seventeen months after root filling . . 193 

1C6 Rabbit apparently killed by the infection in the cementum 
of an implanted tooth, after dentin was treated with 
silver nitrate and formalin ...... 196 

108 Two similar wax bars placed in a warm investment and cast. 

A, before heating; B, after heating and while investment 
was still soft, showing the changes in the wax and the shape 
of the casting ........ 200 

109 Gutta-percha under a high pressure inside of glass tubing, to 

test the shrinkage of cooling gutta-percha. Note the ink 
flowed freely into the shrinkage space .... 202 

110 Shows the multiple foramina, branchings, enlargements, and 

constrictions in the root apex ...... 205 

111 Root canal filling shrinkage. A, as roentgenographed in the 

mouth; B, after extraction; C, a cross section of the tooth 

and root filling ........ 207 

112 Infected laterals which have given frequent and severe 

discomfort ......... 210 

113 Teeth formerly with fistulae and recurring tenderness, latterly 

comfortable. All badly infected . . .211 

114 Infected teeth with no historv of discomfort . . . 213 



XIX 

LIST OF ILLUSTRATIONS Continued PaG i 

116 Dental caries extending along the tubuli toward the pulp. 

Upper is cavity end of tubuli, lower near pulp 21 / 

117 Acute endocarditis, with extensive vegetation on valve cusp, 

produced in a rabbit's heart by the intravenous injection of 
tin- organisms washed from a single root-filled tooth. These 
organisms weighed approximately one millionth part of a 
gram . . . .218 

118 Two views of a molar tooth producing no local discomfort 

for the patient but which killed many rabbits in succession, 

on an average of four days ...... 220 

119 Shows a small glass tube carrying chips from an infected 

tooth. Its size can be judged by comparison with the tooth 223 

120 Rabbit reactions to open end tubes carrying different sub- 

stances. A, virulent culture; B, same organisms with two per 
cent phenol; C, normal salt solution; D, another dental 
culture; E, filtrate from culture A; F, supernatant fluid 
from centrifuged A ....... 224 

121 Appearance of a sterile coin two months after implanting 

beneath a rabbit's skin. No fibrous capsule formation 

or irritation. A slight etching of the coin ... 225 

123 Two brother rabbits of corresponding size and weight. Al- 
ways under same environment. A, the upper, was injected 
intravenously with 1 cc of the clear centrifuged washings 
of an infected tooth; B, a control. A lost 37 r ( ' and died in 
five weeks and B gained 12% - . . 230 

138 Upper. Typical appearance of lungs of a rabbit inoculated 

intratracheally with the washings from the nose and throat 
of a flu patient. Lower. A fatal streptococcal pneumonia 
in a flu rabbit produced by a simultaneous injection of a 
dental culture . ...... 269 

139 Shows a section of the lung of a rabbit which died of strepto- 

coccal pneumonia from a dental culture. The bronchioles 
are obstructed by the thickening of their lining membranes 
and by the emphysema. . . . . . .271 

140 A rabbit in which complete paralysis was produced from the 

center of the spine backward, by dental culture infection. It 
apparently recovered almost completely except for atrophy 
of a few muscles which produced a twisted leg 273 

141 Mews and sections of the spine of rabbit shown in Figure 

140. Note destruction of intravertebral cartilage in A 
and B; destruction of body of vertebra in C; and mild 
condensing osteitis in D and E . . . . . 274 

142 A and B show two rabbits which developed acute suppurative 

arthritis from small injections of dental culture, plus chill- 
ing in cold water. The two controls receiving the same 
culture but not chilled developed no lesions 277 

144 Multiple kidney abscesses produced in three rabbits. All 
received the same culture and the same time factors. Re- 
sults are inversely with the weights of the rabbits 290 

152 Spontaneous hemorrhages causing death in twelve hours. A, 

thigh; B, chest wall; C, heart muscle; D, stomach lining 304 



XX 

LIST OF ILLUSTRATIONS— Continued Page 

153 Second rabbit with same culture as Figure 152. A, other thigh 

of Figure 152; B and C, another rabbit receiving same cul- 
ture; B, hemorrhage into knee; C, back muscles . . 305 

154 Less severe lesions produced by later generations of same 

culture. A, hemorrhage from eye; B, back muscles; C, 
chest wall ... 307 

155 Diagram of the apparatus which uses a section of tooth as a 

permeable membrane. A, tooth section; B and C, con- 
tainers for solutions being tested . . . . .315 

159 Proliferative arthritis shown in shoulders in B. A, normal; 

B, had received lethal doses of dental infection but had 
apparently survived because of the raising of its defense by 
chemotaxis ......... 334 

160 A case of periodontoclasia treated with ultraviolet rays from 

a quartz mercury vapor arc. A, is without gutta-percha 
points in pockets, and B with. Note how deceiving A is 339 

163 The microscopic appearance of a section of a tooth with an 

arrested caries. Two magnifications .... 362 

165 Roentgenographic appearance of the teeth. Patient suffering 

with sensitization reaction from his dental infection, shown 

in Figure 166 ........ 369 

166 A, a recurring acute inflammatory sensitization reaction pro- 

duced in a patient by his dental infection; B, a rabbit which 
developed acute lacrimation and rhinitis in forty minutes 
after inoculation with washings from this patient's crushed 
teeth .......... 371 

167 Normal vascularization of mesenteries, intestines, and testicles 

of a rabbit 375 

168 The vascularization of mesenteries, intestines, and testicles 

of a rabbit sensitized with the washings of a crushed tooth . 376 

169 The vascularization of the mesenteries and intestines of a 

rabbit injected with histamine ..... 377 

170 Two mild and one strong positive reactions in a rabbit's ear 

that had been sensitized to a dental toxin . 377 

171 Upper. Three positive primary dermal reactions on the arm 

of the patient shown in Figure 166. Lower. One positive 
secondary reaction from same patient . . .379 

172 A scaly dermatosis, with marked stiffness of fingers. A, upper, 

before removal of dental infection; B, lower, after . .381 

173 The dental infection involved in the skin lesion of Figure 172 . 382 

174 The dermal reactions of the patient in Figures 172 and 173. 

A, primary; B, secondary ...... 383 

175 First, a persistent dermal irritation; second, the same arm 

with two primary positive reactions from his dental infec- 
tion; third, the same arm one week later. There was no 
recurrence in nine months ...... 385 

176 Roentgenographic record of the teeth of the patient shown in 

Figure 175 ... . . 387 

178 Skin cancer of the nose and its appearance three weeks later 

after removal of dental infections. See text . 393 

179 Roentgenographic record of the teeth of the patient shown 

in Figure 178 394 



XXI 

LIST OF ILLUSTRATK )NS Continued i- A > 

180 Marked tissue atrophy produced by injection of a dental cul- 
ture, twenty per cent in four days. No cleft between eyeball 
and socket 102 

1S1 Typical marasmus in rabbit inoculated with clear washings 
from crushed tooth of patient. Rabbit lost 11', in sixteen 
days ... .403 

183 Dead fetal forms following injection of 1 cc of dental culture 1< >7 

184 Abscess on neck shown in A; amcba infection shown in B; 

origin from infected tooth socket shown in C 410 

185 Spirochetal abscess produced in rabbit in A; B, culture of 

same . . . . .411 

186 Culture of spirochetes from trench mouth, which caused pa- 

tient to lose eighteen pounds in three weeks. With local 
treatment he gained ten pounds in two weeks . .411 

187 Ameba infection deep in the gingival tissue .412 

188 Organisms in an haversian canal, adjoining a periodontoclasia 

pocket ... 413 

189 Two rats same age, one on normal diet and the other deficient 

in Vitamin B ... .417 

190 The rats on the deficiency diet have also less resistance for 

infection ....... 417 

191 Two rabbits which developed ovarian cysts. Patient fur- 

nishing culture had recently been operated for same . 429 

192 Normal rabbit pancreas ....... 430 

193 Pathological rabbit pancreas ...... 430 

195 Front view. Changes produced by slowly opening the median 

suture. Case No. 111. Age sixteen. In about twelve 
weeks he passed through the changes of adolescence, rapidly 
growing a mustache, etc. 
Side view. Changes produced by slowly opening the median 
suture. Case No. 111. Age sixteen. The mental changes 
were also very great. He passed from playing with blocks 
to the interests of developing boyhood, telephoning, 
reading, etc. ........ 437 

196 Roentgenographic changes by days from opening the median 

suture .......... 438 

197 Appearance of a degenerating granuloma. Patient has lost 

her defense. Insert shows roentgenographic appearance 443 

198 A protective mechanism of dental granulomata . 444 

199 Highly vascular granuloma of Figure 198 .... 446 

200 Resorption processes in C and D, from point of arrow in B; 

A, roentgenographic appearance . . . .448 

201 Appearance of dime planted two months. Note no cyst for- 

mation . . . .... 449 

202 A group of encapsulations about implanted teeth; produced 

by the rabbits, and the roentgenographic views of same. Note 
absorption of tooth, B-l, C-l. D-l .451 

203 A shows, roentgenographically, a tooth implanted beneath 

the skin of a rabbit, which had been removed from a patient 
suffering with nephritis. B and C show two sections of that 
rabbit's nephritic kidney when it was chloroformed some 
weeks later ......... 4o2 



XXII 

LIST OF ILLUSTRATIONS— Continued Page 

204 Two granulomata. The left was developed by the rabbit 

about the implanted tooth; the right by the patient from 
whom the tooth was extracted ... 453 

205 Shows an abscess produced under the skin of a rabbit by the 

implantation of a root of the molar shown in C. See text . 454 

206 A vigorously functioning granuloma in a patient of a high 

defense ..... . 460 

207 The roentgenographic and photographic views of granulomata 

which protected the patient until about eighty years of age . 460 

208 A highly functioning granuloma. Note the large amount of 

epithelial tissue . . . . . . .461 

209 An implanted tooth which the rabbit carried thirteen months. 

It died of nephritis, from which the patient was suffering. 

C, the encapsulated tooth; B, casts from the rabbit's urine . 462 

210 A sterile implanted tooth which produced practically no 

encapsulation . . ...... 463 

211 Encapsulations about boiled infected teeth. Heating did not 

destroy the toxin ....... 465 

212 One of several rabbits which developed pneumonia following 

the implanting of an infected tooth. A, pneumonic lung; 

B, the encysted tooth ....... 466 

213 Tooth was heated to 56° for one hour before implantation 467 

214 Shows the reduced bacterial growth in the vicinity of a well 

organized granuloma when placed on an infected petri dish . 468 

215 A, the roentgenographic appearance of the dissections in B 

and C. Note pocket between second and third molars and 
adjoining radiopacity. B and C show the arrangement of the 
calcified structures ....... 471 

216 Enlargements of preceding to show trabecular arrangement and 

condensing osteitis surrounding a periodontoclasia pocket. 

A late stage 472 

217 A, osteoclasts in the process of removing alveolar bone in 

periodontoclasia. B, a cross section of the tooth and sup- 
porting alveolar bone ....... 473 

218 A proliferative arthritis in a rabbit's shoulder. A, D, and F 

show normal scapulae; B, C, and E grossly deformed . 476 

219 A degenerative arthritis in a rabbit's hip joint. A, normal 

heads of femora? ; B, destruction of entire articulating sur- 
face 478 

220 A degenerative process in trabecular and cortical layer of a 

rheumatic joint ........ 479 

221 Beginning inflammatory process in the synovial membrane 480 

222 Diplococci seen in a smear from a rheumatic joint . .481 

223 A cross section of a tooth under orthodontic pressure. Note 

absorption on the advance side of movement . . . 482 

224 A, B, and C osteoclastic activity; D, hemorrhage into pulp 

of tooth of previous figure ...... 483 

225 Progressive development of radiopacity of second bicuspid 

of patient with deforming arthritis. A, in vear 1901; B, 
1914; C, 1916 487 



XXIII 

LIST OF ILLUSTRATIONS Continued page 

226 Six teeth which became non-vital in succession in the mouth 

of a patient with deforming arthritis 189 

227 Osteoclastic absorption of tooth structures and calcification of 

pulp in a patient with deforming arthritis 489 

228 Absorption of cementum and dentin as part of arthritic disease 

of tooth shown in Figure 'I'll . 190 

229 Osteoclastic activity, high power, of Figure 228 191 

230 Osteoclastic reaction produced by rabbit: A, in an arthritic 

joint ; B, in an implanted and encysted tooth 492 

231 Calcifications in the pulp of tooth shown in Figure 227 493 

232 Cross section of a decalcified pulp from a patient with arthritis 493 

233 Roentgenographic appearance of tooth with completely decal- 

cified pulp, shown in Figure 232 ..... 494 

234 Arthritic changes in external surfaces of tooth with calcified 

pulp from arthritic patient . . . 495 

235 Arthritic hypertrophic nodule on root . 496 

236 Cross section of hypertrophic nodule, shown in Figure 235 496 

237 Skin lesion of rabbit which lost 28 per cent in weight in twenty- 

two days, from implantation of calcified root from arthritic 
patient ......... 497 

238 High magnifications of sections of calcified pulp. Note den- 

tin-like structure in B . . 498 

239 Section of alveolar bone fused into a root following an in- 

flammatory reaction ....... 499 

240 The migration of leucocytes into a glass tube, a chemotactic 

reaction with toxin ....... 502 

241 A comparison of a drop of blood from a defective patient— 

A, with a normal patient — B. Note the clear zone in B, 
inhibiting bacterial growth ...... 505 

242 Studies of bactericidal property of blood, one minute ex- 

posure .... ..... 5C6 

243 Comparison of bactericidal property of blood of a normal and 

an infected rabbit ....... 507 

244 Comparisons of bloods of two individuals .... 508 

245 A blood with a high defense, from a patient recovered from 

systemic involvement ....... 509 

246 Bactericidal properties of bloods: A, normal human; B, 

broken defense; C, broken defense plus tooth toxin .511 

247 Roentgenographic appearance of the teeth of the patients re- 

ferred to in Figure 248. B, Case No. 1414, with low defense; 

A, 1415, with high defense ...... 514 

248 Comparison of bactericidal capacity of bloods of two patients 

presenting same hour. Case No. 1414 has low defense with 
heart involvement; Case No. 1415, with high defense and 
normal. (See dental conditions in Figure 247 1. . . 516 

251 Two rats with teeth planted beneath the skin, one completely 
extruded and the other nearly so. Their high defense makes 
this possible ........ 524 

254 Specimen chart outlining tests to be made and their controls 

for determining bactericidal capacity of the blood . 537 

256 Maxillary osteomyelitis following apical abscess . 547 



XXIV 

LIST OF ILLUSTRATIONS Concluded Page 

258 Heart of a rabbit with endocarditis and myocarditis: A, gross 
appearance; B, appearance of section of heart muscle with 
multiple degenerative and necrotic processes . 548 

262 Case No. 1268. Roentgenographic appearance of a case with 
a profuse flow of pus, exuding with every movement of the 
teeth. Neither the patient nor any member of the family 
group had had rheumatic group lesions. Chemical analysis 
of blood and urine reveals that he has already a severe 
hyperglycemia and glycosuria. The patient had no sus- 
picion that he had diabetes. ...... 577 



- 



LIST OF FOUR COLOR ILLUSTRATIONS 

ACUTE PULPITIS Frontispiece 

Symptoms Hypersensitiveness to Thermal Change. Ilis- 
topathology Interstitial Hemorrhage into Dental Pulp 
from infected Caries. 

Figure 

3 Comparison of the apparent with the actual. A and B show, 
roentgenographically, two maxillary molars. Note their 
difference. A 1 shows the periapical granulomata attached 
to the roots of A. and B' the periapical granulomata attached 
to the roots of B. The zones of rarefaction in A and B are 
obscured by zones of condensing osteitis .... 39 

138 Upper. Typical Appearance of Lungs of a Rabbit Inoculated 
Intratracheally with the Washings from the Nose and 
Throat of a Flu Patient. Lower. A Fatal Streptococcal 
Pneumonia in a Flu Rabbit Produced by a Simultaneous 
Injection of a Dental Culture . 269 

246 Bactericidal Properties of Bloods. A, Normal Human: B, 

Broken Defense; C, Broken Defense Plus Tooth Toxin 511 

166 A, A Recurring Acute Inflammatory Sensitization Reaction 
Produced in a Patient by his Dental Infection; B, a Rabbit 
Which Developed Acute Lacrimation and Rhinitis in Forty 
Minutes After Inoculation with Washings from this Patient's 
Crushed Teeth ........ 371 

171 Upper. Three positive primary dermal reactions on the arm 
of the patient shown in Figure 166. Lower. One positive 
secondary reaction from same patient .... 379 

174 The dermal reactions of the patient in Figures 172 and 173. 

A, primary; B, secondary. ... . . 383 

175 First, a persistent dermal irritation; second, the same arm with 

two primary positive reactions from his dental infection; 
third, the same arm one week later. There was no recurrence 
in nine months ....... 385 



XXV 



17 
18 
19 
20 
21 
22 
24 
41 

42 
43 

44 

45 



46 

47 

48 
49 

81 

82 
83 
84 
85 



86 

87 
88 

96 
103 
104 
115 
122 
124 
125 



LIST OF CHARTS— VOLUME I 

Relative Prevalence of Different Strains 

Bacterial Classification in Relation to Tissue Affected 

Formalin ....... 

Iodoform Saturated in Alcohol .... 

Alcohol 

Phenol. Thalium Sulphate 

Comparison of Washed Organisms and Whole Cultures 

Rheumatic Group Lesions of Individuals and Their Relatives 

Susceptibility Studies by Alphabetical Groups . . . 93-94 

Comparisons of Susceptibility Groups .... 98-99 



Page 
57 
57 
59 
61 
61 
61 
65 



Mendelian Factors ........ 

A Progressive Study of the Relation of the Susceptibility 

Factor of Individual Patients to That of Their Relatives 
A Study of Susceptibility of Various Groups of Patients With 

Rheumatic Lesions Which Are Apparently Related to 

Dental Focal Infections 
Comparisons of Two Separate Studies. Relative Prevalence 

of the Following Lesions in Affected Patients 
Dominance of Special Tissue Lesion in Both Patients and 

Families (Ten) ....... 

Mendelian Factors .... . . 

Relation of Local Structural Changes to Svstemic Suscep 

tibility ' . 

Relation of Caries to Susceptibility to Rheumatic Group 

Lesions. 15 Typical Families to Each Group . 
Relation of Caries to Susceptibility in 681 Individuals . 
Relation of Caries to Type of Rheumatic Group Lesions 
Relation of Caries to Systemic Susceptibility 
Relation of Periodontoclasia to Susceptibility to Rheumatic 

Group Lesions. 15 Typical Families in Each Group. 

Group Two ........ 

Relation of Periodontoclasia and Systemic Susceptibility 

Group One ....... 

Relation of Periodontoclasia to Systemic Susceptibility 
Relation of Periodontoclasia to Type of Rheumatic Group 

Lesions ..... 

Relation of Local to Systemic 
Root Canal Medications 
Root Canal Medications 
Change in Weight of Tooth Structure 
Rabbits with Subdermal Implantations 
Comparison of filtered and unfiltered Washings 
Erythrocytosis Produced by Tooth Implantations 



100 



100 



102 

104 

104 
104 

111 

155 
155 
156 
156 



159 

160 
160 

161 
174 
187 
187 
216 
226 
231 
235 



XXVI 



XXVII 



126 
127 
L28 
129 



LIST OF CHARTS Continued p AG i 

Erythropenia 23 i 

Leucocytosis Produced by Tooth Implantations 236 

Leucopenia Produced by Tooth Implantations 237 

Effect of Tooth Implantations in Depressing Polymorphonu- 
clears and Increasing Lymphocytes. 238 
130 Patients with Depressed Polymorphonuclears and Increased 

Small Lymphocytes 239 

131-A Comparison of Blood Chemistry, Dental Pathology, and 

Systemic Involvements 242 

131-B " •• 243 

131-C - - 244 

131-D - - 245 

131-E .•■•'.. . 246 

131-F '• •■ . 247 

132 Effect of Treatment on Ionic Calcium of Blood 251 

133 Blood Calcium Changes Produced by Infected Teeth . 25 1 

134 Chemical Changes in the Blood, Produced by Implanting 

Infected Teeth Subdermally, and the Relation of the 
Changes of Ionic Calcium and Body Weight . 257 

135 Comparison of Changes in Ionic Calcium and Blood Mor- 

phology, Due to Culture Inoculations .... 258 

136 Depression of Ionic Calcium by Implanting Infected Teeth . 258 

137 Oral Infections and Influenza Complications . . 267 
143 Summary of Animal Reactions and Patients' Symptoms 288 
1 15 Muscles and Joints . 291 

146 Eyes ... 293 

147 Digestive Tract . . . 297) 
1 is Generative Organs . . . .297 

149 Hearts . . 299 

150 Organ Susceptibility ... 300 

151 Progressive Tissue and Organ Involvement of Croups . . 302-3 

156 Characteristic^ of Active and Deficient Immunity 323 

157 Comparison of Tooth Toxin and Tooth Culture. A. Tooth 

Washings. B. Tooth Cultures . 327 

158 Chemical Means for Increasing Defense . . 333-1 

Section I. Eight Control Rabbits. 

Section II. Rabbits Injected with 
hydrochlorate Before Culture. 

Section III. Rabbits Injected 
hydrochlorate After Culture. 

Section IV. Rabbits Injected 

hydrocupreinhydrochlorate Simultaneously. 

Section V. Rabbits Injected with Ethylhydrocuprein- 
hydrochlorate Alone. 

Section VI. Rabbits Injected with Chaulmugra Oil Com- 
pound Before Culture. 

Section VII. Rabbits Injected with Chaulmugra Oil Com- 
pound Alone. 



Ethylhydrocuprein- 
Ethylhydrocuprein- 
with Culture and Ethvl- 



with 



XXVIII 

LIST OF CHARTS -Concluded Page 

161 Effect of Radiations on Blood of Normal Rabbit . 340 

162 Effect of Radiations on Blood Calcium of Normal Rabbit 341 
164 Sensitization Reactions to Tooth Toxins .... 366 
177 Dermal Sensitization Developed in Rabbits . . . 390 

A. Ear used as test. 

B. Abdomen used as test. 

182 Per Cent Loss or Gain in Weight After Inoculation of 667 

Rabbits . . 404 

194 Effect of Parathyroid and Calcium Lactate Treatment on 

Ionic Calcium of Blood . 434 

249 Lymph Experiment ........ 520 

250 Changes in Rats with Planted Teeth — Normal and De- 

ficient Test ......... 521 

252 Bactericidal Power of Blood .... 531 

253 Ionic Calcium, Sodium Salicylate, and Diet Factors . 534 
255 Relation of Alkalinity Index to Calcium .... 544 
257 Acid-Base Relation to Symptoms and Treatment . 547 

259 Alkalinity Index of Blood of Patients . 557 

260 Acid-Base Relation to Symptoms and Treatment 558 

261 The Relation of Alkalinity Index to Calcium . . 561 



PREFACE 

r T 1 HE PURPOSE of these two volumes is to present new data 

and important new interpretations suggested by than. I wish to 

assure the readers of these volumes that I am not unmindful of 

the tremendous responsibility that is involved in my presuming to 

furnish to the medical and dental professions a new interpretation 
of the pathology of oral and systemic expressions of denial 
infections and of their role in the production of the degenerative 
diseases. Notwithstanding this great responsibility, however, 
I have a sense of deep confidence that the new interpretations, 
I am hi reieith presenting, more adequately harmonize the available 
evidence and clinical findings than do any that we have had 
heretofore. 

This title presumes that dental infections have been demonstrated 
to be an important contributing factor in the production of the degen- 
erative diseases. I have no hesitancy in leaving to the evidence here- 
with submitted, whether I am justified in using this title; and now 
that we see it in the new light, we understand with a kindly sympathy 
the ?nisapprehensiotis and the causes for the confusions of the past. 
It is probable that there seldom has been and seldom will be in the 
history of humanity, so universal a misapprehension based upon 
misconceptions, if we may judge importance on the merit of factors 
involved. Briefly stated, this misapprehension has been this. We 
have mistaken effect for cause. Since everything is relative, infection 
has had to have a quantity factor, and that quantity factor has 
had to be measured. The measure has been the structural change 
at the point of the focus. This has presupposed that quantity and 
virulence of organism, on the one hand, determined in large part the 
danger to the host. With this as the fundamental, it has been practi- 
cally universally conceded that comfort and serviceability were 
dependable symptoms of safety and efficiency. But this being the 
fundamental conception, it has been most natural that exceptions 
to this rule would challenge the presumption that a large enough 
quantity of dental infections would do harm, whereas a small 
quantity would not. There has, accordingly, been a paradox that 
heretofore has been unanswered, and which probably has been the 
basis for nearly all of the opposition to the proposition that dental 

19 



23 PREFACE 

injections could do systemic harm. Such a one has been the following: 
In the various out-clinics of hospitals and in such groups where 
large numbers of individuals could be observed, it has been continually 
noted that those individuals with apparently the largest quantity of 
pus exuding from infected roots, and particularly from apical 
fistulx, had no rheumatism, heart, or kidney involvement; and in 
those cases where these lesions did exist, there was no such evidence of 
discharge. If, then, these individuals with so much infection were not 
involved, why strain the point so far as to assume that less infection 
was the cause in these other individuals? The fundamental concep- 
tion has been wrong, for the individual with the large quantity of pus, 
as evidenced by the flowing fistulx, did not necessarily have more 
infection that those of the other group who, with similar conditions, 
had no such physical expressions. The difference is in the individ- 
uals of the two groups, and this is one of the important new truths 
that these volumes will bring, and is a difference in the capacity for 
reaction. The teachings of the past have assumed that there was a 
distinct difference in the attacking power and virulence as well as the 
quantity factor involved in different dental infections. These reports 
will show that our problem is not one, primarily, of the morphology 
and biological characteristics of the strain involved, but, on the con- 
trary, any strain of the streptococcus group, which may chance to get 
into that environment, will tend to produce the same unit charac- 
teristics, and that these characteristics will, because of the very great 
adaptability of these organisms, be the resultant of the pabulum 
furnished by the host as the culture medium for the strains involved. 
Further, I have shown that an individual' 's defense for the strep- 
tococcal group of infections is primarily a matter of a special defen- 
sive factor or mechanism for the streptococcus group, which factor he 
inherits from his ancestry just as he inherits all his other unit char- 
acters, that (his quality has a unit basis in relation to individual 
organs quite independent of the entire body. This normal defensive 
factor is a relative one and is subject to modification through a wide 
range as a result of overloads. The individual, therefore, with a high 
defense, expresses that defensive capacity immediately about the 
tooth, for he efficiently resists the invader immediately about the point 
of entrance. This warfare will be shown to be a matter of the estab- 
lishment and maintenance of a local and systemic quarantine, the 
mechanisms for the development and maintenance of which are 
brought out in succeeding chapters. I have shown that these very 
defensive factors are all measurable and can be expressed 



PRE] U 21 

quantitatively by chemical analysis of various factors of the 
blood and by determining the bactericidal properties of the 

blood. 1 1 is a most significant and lamentable fact, Hail then 
has bun practically no important progress in our under- 
standing of the etiology of periodontoclasia, or pyorrhea alveolar is, of 
'he etiology of denial caries, or of the true relation of denial infections 
to systemic disease except in the most general terms, in a whole cen- 
tury, and this, fundamentally, because the accepted doctrines had no 
basis in experimental pathology, bill icere a matter of inheritance 
from preci ding generations and were the logical assumptions. These 
new interpretations, which I furnish herewith, as well as the data 
from which I hare drawn them, adequately explain the denial para- 
doxes as being precisely what we should have expected, and as being 
i)i complete harmony with this newer view. 

This work must stand or fall absolutely on its merits in this regard, 
and I have no hesitancy in sending this bark out into the storm which 
I know must follow, and I have no desire that it shall weather the 
storm if its cargo is not entirely that of truth. The very large scope of 
the presentation precludes the possibility of the detailed argument 
and presentation of data thai will be desirable simply in a critical 
review. I have, accordingly, undertaken to make this serve the 
double purpose of being directly applicable to clinical practice (for it 
has grown out of the most exacting and intimate study of clinical 
relations i and to furnish an adequate amount of experimental data to 
establish and justify the new interpretations. The data, that I am 
furnishing, are only a small fraction of what 1 have available. 

With regard to the timeliness of such a message, there is no ques- 
tion or doubt. 

This can perhaps best be summarized by suggesting the present 
stage of advancement of general medical and denial knowledge. This 
teas splendidly done at the recent meeting of the American Associa- 
tion for (he Advancement of Science (Boston, December 26-30, 1922) 
when a general session was addressed by Dr. Livingston Far rand, 
president of Cornell University, on the subject, "The nation and its 
health." Science, in abstracting his address, stated: 

"Dr. Farrand reviewed the progress of public health work in this 
country and pointed out that since 1870 the average length of life has 
been increased by fifteen years, that marked reduction has occurred 
during this period in infant mortality and in mortality due to tuber- 
culosis, typhoid, smallpox and many other diseases. The efforts of 
health workers and organizations have, however, been unable thus far 



22 PREFACE 

to prevent increases in certain unconquered diseases, such as cancer 
and diseases of the heart and kidneys. The most outstanding prob- 
lem at present concerns the control of the degenerative diseases of later 
life, an increase in mortality from these being an inevitable conse- 
quence of improvements in the control of diseases of infancy and 
youth." 

If, as I interpret these researches to demonstrate, the degenerative 
diseases to which he refers, particularly of the heart and kidneys, are 
very markedly increased in their severity and in many instances 
actually caused by dental focal infections, there probably is no more 
important problem for our modernly civilized communities than the 
study of means for the prevention, in every way possible, of these 
degenerative processes. 

Few, if any, of the contributors to medical science have shown a 
greater appreciation of this need and deserve greater credit for the 
danger signals given to the profession and humanity, than Sir 
William Hunter. In a recent discussion by him before the Medical 
Society of London (December 11, 1922) he called attention to the fact 
that the present discussion in which he was taking part was the first 
which had taken place on oral sepsis before that society since the 
subject originated in its newer phase in the paper presented by him 
before that society twenty years ago. In the paper which he was dis- 
cussing Sir William Willcox had given a general resume of the 
literature without new experimental data and had stated that he 
agreed with Dr. Beddard who had expressed the opinion that 90 per 
cent of the non-specific infective arthritis cases were due to infection 
arising from the teeth. Lord Dawson in closing the discussion 
stated that the subject afforded a very good example of a necessity for 
teamwork, that what was wanted was some really connected work 
upon the subject to which dentists, radiographers, and bacteriologists 
would all contribute. 

In conducting the researches herewith reported, I have undertaken 
to secure the closest cooperation possible by engaging men for my 
staff, whose exclusive attention has thereby been concentrated on the 
particular phase for which they were engaged. There has, therefore, 
been the closest possible cooperation without the possibility of dis- 
traction or conflicting purpose; and I am profoundly indebted to 
these collaborators, who have been many, during these two and one- 
half decades, in working on these problems. 

No work on this subject can be presented at this time, if at any 
time in the future, without recognizing in a very important way the 



PREFACE 23 

( tceptional pioneer work that has been done by Dr. E. C. Rosenow, 
first while working in Chicago at the Presbyterian Hospital in 

association with Dr. Frank Billings, and latterly in the Mayo 
Institute at Rochester, Minnesota. Probably to Dr. Billings n; 

than to any other American internist is due the credit for the early 
recognition oj the importance of streptococcal focal injections in 

systemic involvements, for his work practically paralleled that of 
Sir William Hunter in England. 

I wish to express my deep indebtedness to all these pioneers in this 
field; and if my work shall hare removed some of the confusions 
which have been largely responsible for the lack of appreciation of, and 
opposition to. the efforts of these great pioneers. I should be doubly 
glad because of my esteem for their courage in the midst of the bitterest 
of opposition, and also for the larger helpfulness that may come to 
humanity by a more universal medical and dental appreciation of 
this need. There could not possibly be a stronger tribute to the sincer- 
ity of these men than that they should so persistently follow the line of 
their conviction in the midst of the unprecedented antagonism, for 
theirs was the vision of a great new truth. 

It is my judgment that (he most important phase of this contribu- 
tion will not be simply the correcting of a misconception of funda- 
mental dental pathology, but the making of an important new contri- 
bution to the pathology of focal infections and the dengerative 
diseases. In the light of the succeeding chapters there is strong evi- 
dence that the degenerative processes which ice have thought of as 
various diseases, such as Bright's disease, heart disease, nervous 
system involvement, digestive trad disfunction, etc., etc., are primarily 
the end products of disturbed processes of metabolism and catabolism, 
and that em important contributing factor to these disfunctions will be 
found to be focal infection, whether of dental or other origin. Since, 
however, they develop most largely in adult life, more than 95 per cent 
of the members of the human race will be found to have a source in the 
form of an infected non-vital tooth for the disturbers of the hormones 
which control organ and tissue functions. The evidence in these 
chapters will take the form of the measurement of these factors, tin 
reproduction of the various cycles of animal experimentation, and 
numerous evidences of the elimination or betterment of the human 
physical disfunction and organ degeneration following tin removal 
of the dental infection. 

While the preparation of this text has involved a series of researches 
extending over more than twenty-five years, it has not seemed to me 



24 PREFACE 

wise to publish a less complete statement for the following reasons: 

The earlier researches involved seemed to establish that the current 
fundamentals, as universally accepted, were not based on truth; and 
I soon learned from the presentation of papers and illustrated lectures 
that the bringing to the profession of a negative statement, simply 
challenging the old fundamentals without putting something in their 
place, was a very unwelcome message. The role of an iconoclast is 
seldom, if ever, a happy one. 

Second, while it was a relatively simple matter to demonstrate that 
the accepted fundamentals were in error, it has been a tremendously 
difficult matter to develop new working hypotheses that would stand 
the most critical test that I have been able to put to them. 

Third, a new interpretation must, by the very nature of things, and 
it is well that it is so, run a gauntlet of intensive criticism, which not 
only is right, but becomes a purifying fire; for only by the most 
exacting tests should new truths presume to supplant old ones. 

It is a matter of deep regret to me that so much of my energy has 
had to be expended in the business side of dentistry in order that the 
means might be available for conducting these investigations, which 
has not left an adequate amount of time and strength to perfect these 
volumes to a greater degree. 

It has been impossible because of the voluminous presentation, for 
me to include an historical review and bibliography for each chapter, 
which, in themselves, would add many hundred pages. 

These researches have required the use of approximately five hun- 
dred rabbits a year, for several years; and, for those who would criti- 
cize their use, I wish to state that many of these rabbits have in my 
judgment made afar greater individual contribution and service to the 
welfare of humanity than hosts of human beings. Rabbits that run 
wild and are chased by their enemies have not been as well fed and as 
happily housed, or been privileged to die under chloroform. I have 
had many patients express their gratitude and confidence by offering 
themselves for any experiments that I would care to try upon them, if, 
by so doing, they too could help humanity. The greatest tragedy that 
I see in the whole development of this subject in the past, has been 
that humans alone have been used as the experimental material and 
the experiments have not been properly checked; for it has been con- 
sidered that comfort and serviceability were a sure proof of the suc- 
cess of the experiment, entirely misapprehending that a lack of reac- 
tion about the tooth, and the consequent comfort, only meant that the 
quarantine was not in operation and the toxin and bacterial invasion 



PREF u 

were passing to otht > funis of the body, tin re to break dou n tissin and 
shorten life. 

I am deeply indebted to many persons for assistant in the develop- 
ment of this work. Firs! of all. I want to pay the highest tribuU 
possible to tin patients who ban given me every possible co'dpi ration. 
While I han no doubt tiny ult a gratification for relief given thou 
from distressing symptoms, and distinct improvement in health and 
comfort of living, the spirit in which they hare cooperated not only 
by paying liberally for the services as they were charged to Hum, but by 
material contributions made in many instances to the work, without 
which it could not hare been so efficiently conducted. For those who 
arc unfamiliar with the unusual expense of this type of work, it will 
be of interest to note that the research work involved in these two 
volumes has cost in excess of $250,000, which has been provided 
almost entirely by the fees from the patients. 

I wish especially to (hank all the members of my staff are raging 
sixteen in the last three years, and seldom less than fire during the 
preceding twenty-fire years in which I hare been doing this work. It 
is true that we hare had a common joy in this service to humanity, but 
I cannot pay too high a tribute to the earnestness and completeness 
with which they hare joined in the search for these new truths. I can- 
ned imagine a greater joy in any enterprise than that which they hare 
given me by the earnestness and completeness of their cooperation. 
This work could not hare been done without this superior assistance 
and cooperation. The length of the list, and the extend of the time 
over which the work has been in progress, preclude their individual 
mention. 

I am also deeply indebted to several friends who have given me 
encouragement that has been exceedingly helpful, and who, by their 
deep interest and constant encouragement, hare helped me to overcome 
obstacles that seemed very forbidding. 

Volumes One and Two, herewith presented, are so interrelated and 
inseparable in context, being but different phases of the same prob- 
lem, that they are treated as a unit and neither volume should be con- 
sidered apart from its cross references to the other. Those who an 
familiar with the expense of illustrations, and particularly of four- 
color process engravings, will appreciate that no trouble and expense 
hare been spared. The color separation negatives for the four-color 
histopathological plates were made by us directly from the tissue sec- 
tions mot Lumiere or Paget), which is, we believe, a distinct 
adrcnitage orer hand-colored photographs or drawings, all of which 



26 PREFACE 

introduce the personality of the artists. 

I wish to thank the printer and the various engravers for their 
splendid cooperation and assistance in presenting this message. 

Weston A. Price. 

8926 Euclid Avenue 

Cleveland, Ohio 
August, 1923 



INTRODUCTION. 

THE GENERAL STATUS OF HUMANITY AND THE 
HEALING PROFESSIONS. 

Since a now truth is a new sense, because with it an individual 
can see things that he could not see before he had that new truth, 
and things that persons who have not that truth cannot see, it 
must follow that the blindness of ignorance is not only the great- 
est inconvenience but the greatest affliction to humanity. The 
tragic position in which cur modern civilization finds itself with 
regard to dental infections and their local and systemic effects, is 
emphasized by comparison with the absence of similar suffering 
among many less civilized peoples, and it is entirely probable that 
the coming of many of the new comforts which have amounted to 
reformations in our methods of living, has exaggerated to a 
great extent our present conditions. There exists today, in the 
minds of the members of the laity as well as in those of the mem- 
bers of both the medical and dental professions, a confusion of 
ideas regarding dental infections that amounts to a group of mis- 
apprehensions and contradictions leading everywhere to uncer- 
tainty. We feel sure there is no other major affection about which 
there is this maze of uncertainty and apparent contradiction. 
The purpose of this volume and of the extended researches which 
it represents, has been pursued and inspired with the hope that 
it will aid by bringing some fundamental new truths which will 
furnish us all with an additional or new sense which we may 
term a dental infection sense. 

In approaching this subject we should have in mind that 
dental disease is one of the most universal of all the afflictions of 
humanity. As has been emphasized, only a few isolated tribes 
or limited civilizations have been or are free from its curse. Ac- 
cording to cur statistics, over ninety per cent of the children in 
the United States have dental infection in some form. The sta- 
tistics for the cause of absence and tardiness in school work show 
dental infections to be the chief factor, and these largely because 
of the immediate discomfort from dental caries. This, however, 
does not constitute the most serious phase of dental infections: 

27 



28 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES -VOL. I 

namely, their systemic expressions. I am more and more im- 
pressed and convinced after more than twenty-five years of in- 
tensive study of this problem, that the members of the healing 
professions have generally a quite incorrect conception of the 
variety and extent of the systemic expressions of dental infec- 
tions, and this because of the absence of this new sense which is 
just developing with the coming of new, though meager truths. 

Surely, the lay humanity is helpless to save itself, and, as with 
all the other scourges, so many of which have been removed by 
the coming of new senses through new truths, it is dependent 
upon the healing professions for relief and ultimate rescue. Un- 
fortunately, many difficulties have combined to aggravate and 
complicate the already obscure problems. In the first place, the 
lack of cooperation between the medical and dental professions 
has been an incalculable hindrance and disadvantage to both the 
progress of healing science and the well-being of society. Much 
of the research that has been done on this problem has been by 
those who, by the very nature of things, have been handicapped 
by an opportunity to check every detail and check up against the 
clinical. The clinicians have had neither training nor time avail- 
able to interpret their clinical findings in terms of laboratory 
procedure. The whole problem has been clouded by a group of 
contradictions of symptoms which, probably more than all other 
matters combined, has delayed progress. What could be more 
convincing to the medical and dental practitioners that dental 
infections do not have systemic expressions than to find that the 
majority of people examined with extensive dental infections, 
and some exceedingly so, have as yet no systemic disturbance; 
and the converse, that the people suffering severely from obscure 
disturbances, have relatively slight evidence of dental infection? 
If some of the new truths we are presenting in this volume are 
fundamental and correct, as we believe they are, they not only 
harmonize this apparent contradiction but suggest that these are 
just what we should expect. 

The growing tendency for cooperation between the medical 
and dental professions, so long withheld, is a first requisite in 
humanity's behalf. However, until our dental colleges teach 
more of general medicine and clinical pathology, and the medical 
colleges teach more of dental pathology, both local and systemic, 
humanity must wait and suffer. The slow rate of progress of the 
past can only be accelerated by the perfection of organization and 



1\ I R( (DU( I ION 

equipment for research in this field, a first requisite of which is 
the closely cooperating group of specialists working with such 
complete harmony that every step is interpreted in terms of all 

these factors winch arc held in common, as well as those which 
relate chiefly to the field of each specialist. To he more specific, 
the solving of these problems requires the skill and experience of 
each of the following: a well trained clinical dentist who knows 
every detail of the steps in the various operations and of the 
dental structures, physical, chemical, anatomical, and surgical, 
the histcpathologist, biological chemist, general pathologist, 
serologist, and internist. 

We cannot conceive of anything more monumental and per- 
sonal than the responsibility of each and every member of the 
healing professions for the solution in humanity's behalf of this 
problem. The outstanding feature of the present moment is the 
utter meagerness of the effort that is being made to solve this 
problem in proportion to humanity's need. If we would com- 
pare this effort with that, say of farm stock or timber land, it is 
so insignificant as to be a cause for deep chagrin and humiliation, 
if net a consciousness of a misplaced trust on the part of human- 
ity. This has been locked upon as a problem of dental research 
and, as such, has been left largely to the dental profession. En- 
dowments have not been made available and the few workers in 
the dental profession who have had a vision of the responsibility 
and opportunity, have been completely handicapped by lack of 
moral and financial support. Their feeble strength has gone cut 
in battering against a great wall of impenetrable difficulties 
ahead, while they have been flanked on each side by indifference 
and lack of equipment. This is one of humanity's greatest prob- 
lems today and, as such, is worthy of the most splendid support, 
moral and financial, that can be given to any of its interests. 

ANALYSIS OF PRESENT CONDITIONS. 

THE GENERALLY ACCEPTED BASES FOR THE INTERPRETATION OF 

DENTAL INFECTIONS. 

Each dental caries, dental abscess, gingival and alveolar in- 
flammation and necrosis, has been interpreted as essentially infec- 
tive processes, and hence their extent is essentially a measure of 
the infection. It now seems strange that we should have stum- 
bled so long and interpreted the effect, as expressed in extent, as 
a measure of the cause. It has generally been accepted that the 
infection is produced by organisms presenting specific attacking 



30 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

powers for the dental and supporting tissues involved, and par- 
ticularly in the case of gingival infections it has been looked upon 
as being largely a bacterial invasion, contracted by contamina- 
tion with the involved organism. It has been anticipated, that 
the first step in the eradication or prevention of these diseases 
would, of necessity, be the identification of the specific causative 
variety or strain of organism, which would be followed by a suit- 
able warfare against it. We have looked upon various individuals 
as comparable, and hence the effects produced by organisms as 
comparable. On these premises we have accepted a tentative set 
of rules of interpretation, formulated for, and applied to, all and 
various members of the human family. These rules, as generally 
accepted and applied, are about as follows: 

1. Human beings are similar, and therefore comparable in their 
reactions to dental infections. 

2. That dental infections, when they occur at the apices of 
roots, are produced by the invasion of that area by organisms 
frcm the mouth which enter that tissue through the open pulp 
canal ; and that the question of danger from such an infection is 
dependent upon the invasive qualities of that organism. 

3. That roentgenograms of teeth will reveal the presence of 
infection. 

4. That infection will express itself as absorption. 

5. That the apparent extent of the absorption is the extent of 
the infection. 

6. That a given dental infection will express itself in the local 
tissues of the mouth approximately the same in all people. 

7. That a tooth without visible absorption at its apex is not 
infected. 

8. That a tooth with visible absorption at its apex is infected. 

9. That pulps of teeth not exposed by caries are not infected. 

10. That pulps of teeth with periodontoclasia pockets not 
involving the apex are not infected. 

11. That an area of absorption, if present, can be disclosed 
by the roentgenogram. 

12. That the quantity or extent of the absorption is a measure 
of the danger. 

13. That flowing pus from a fistula is, necessarily, very dan- 
gerous to the patient. 

14. That infected teeth can be sterilized readily by medication. 

15. That usual medications do not injure the supporting struc- 
tures. 



l\ rRODl i I ION 31 

16. That root fillings fill pulp canals and continue to do so. 

17. That even a poor root filling is better than none. 

18. That so called modern dentistry is a great and unmixed 
blessing. 

19. That the field of the dentist is the oral cavity. 

20. That a dentist or physician, and especially experts, can 
look at roentgenograms of the teeth and diagnose what should 
be done for the patient. 

21. That local comfort and efficiency of treated teeth are an 
evidence and measure of the success of an operation. 

22. That when infected teeth produce disturbances in other 
parts of the body, it is primarily because the patient is over- 
whelmed by a large quantity of infection. 

23. That the quantity of infection in a tooth with a good root 
filling could net be sufficient to produce serious systemic disturb- 
ance, both because there is no place for bacteria and the quantity 
would have to be large, even teacupfuls, since the germs in den- 
tal infections are understood to have exceedingly low virulence or 
disease-producing power. 

24. That there is adequate information available to practice 
dentistry properly and safely. 

ARE CONDITIONS SATISFIED BY THESE OLD AND CURRENT 
INTERPRETATIONS? 

According to the accepted fundamentals as presented in the 
preceding paragraph, the individuals showing the most extensive 
areas of tissue absorption about dental infections should be con- 
sidered to be the persons having the most serious ones; and, con- 
sequently, we should expect that our worst cases of systemic in- 
volvement would be found in this group. Notwithstanding the 
almost universal belief that this is so, as a matter of fact, when we 
tabulate after careful clinical examination, we do not find that the 
evidence substantiates this, for we find that the individuals with 
these extensive areas of absorption resulting from a given dental 
infection, not only frequently but generally, are the persons but 
slightly affected with systemic expressions during long periods of 
their lifetime. This seems like a paradox and has constituted one 
of the chief closed doors to progress in the interpretation of dental 
infections. Net only does the extent of bone change vary greatly 
in different individuals with a given amount of infection, but 
the type of bone change also distinctly varies with the same cause, 
so far as we can judge regarding kind and amount of dental infec- 



32 DENTAL INFECTIONS, ORAL AND SYSTEMIC-RESEARCHES -VOL. I 

tion. Again, the effect of treatment and the extent and perma- 
nency of improvement are not at all in harmony with the above 
accepted fundamentals; contrary to expectation, there is a wide 
variation in the morphology and biologic characteristics of the 
organisms producing each of the certain types of local tissue 
change and the distinct kinds of systemic disturbance. There are 
also group characteristics that are not satisfied by the preceding 
statement of fundamentals. These group characteristics are 
such that they cannot be harmonized or accounted for en the 
basis of environment, diet, race, etc. 

GENERAL LINES OF INVESTIGATIONS SUGGESTED BY THE OLD AND 
ACCEPTED FUNDAMENTALS AND BY THE CLINICAL CONDITIONS FOR 
DETERMINING THE ROLE OF DENTAL INFECTIONS. 

A careful review of medical and dental literature for the pur- 
pose of finding the origin of the accepted fundamentals and to 
ascertain whether they have been founded upon dependable 
observations, has demonstrated that they seem to have grown up 
much as Topsy did. They have crept into the literature and 
practice of the sciences and have been quite generally accepted, 
apparently without question. One of our first undertakings has 
been, therefore, to check over, as carefully as we might, to deter- 
mine to what extent they were based upon fact. Consequently, 
an enormous amount of really constructive research has con- 
sisted in proving that certain accepted beliefs were not true. 
None, but those who have been so placed, can know the misfor- 
tune of being placed in the position of tearing down the foundations 
and being termed an iconoclast, about which hang some tragic 
chapters of dental history. It has, however, been necessary to 
build new foundations deep down into the substrata of physics, 
biology, and chemistry. We will not review in detail, for lack of 
space, a large volume of research work that has really been nega- 
tive in result, in that it has only proved that the accepted theories 
were incorrect. In general, we have undertaken to determine to 
what extent teeth are infected and what the nature of that infec- 
tion is; to what extent routine procedures have been efficient in 
eliminating dental infection; the efficiency of root-filling methods 
as applied from a physical and mechanical standpoint ; the general 
biological laws underlying susceptibility to dental caries and to 
gingival infections; the local expressions of dental infections; the 
tendency to development of systemic expressions of dental infec- 
tions; the biologic properties of the organisms involved; the ac- 



INTRODUCTION 33 

quired factors which modify these susceptibilities; the influence of 
each diet, environment, habits, altitude, physical and mental 
states, and age. This workhas covered a period of over twenty-five 
years, during which we have used many hundreds of animals and 
have engaged the assistance of skilled bacteriologists, physicists, 
chemists, histopathologists, and serologists; and the deductions 
we are here making should be received as a preliminary report 
since we have not sufficient information, as yet, to make us cer- 
tain that we are able to interpret correctly, and will expect to 
make additions and modifications as further information becomes 
available. 
Some of humanity's unsatisfied conditions are the following: 

Why do seme individuals tend so readily to have periodonto- 
clasia, while others have practically no tendency to it? 

Why dees dental caries become a constant menace for some 
individuals, while others have practically no tendency to it? 

Why is it that when teeth are extracted for some individuals 
the conditions found are so unlike those anticipated, as judged by 
symptoms and roentgenograph^ appearance? 

Why do some individuals always have much trouble from the 
healing cf the sockets after extraction, while others have none? 

Why are tissues about some teeth so easy to infiltrate with 
anesthesia and others so extremely hard? 

What is the so-called dry socket? 

Why do some individuals react with so much depression follow- 
ing even minor surgical operations and react alarmingly from 
extensive operations, and how can they be anticipated? 

Why are some cases of periodontoclasia and suppurative 
gingivitis and alveolitis so resistant to treatment and others so 
amenable? 

Since some teeth have, because of conditions, an intrinsic value 
to the patient that is very great and since similar teeth may in 
some cases do harm that is very great, how can we determine 
with relative safety when they should be retained and when 
removed; or otherwise stated, how can we establish the factor of 
safety of a given patient in relation to a given tooth? 

When do given dental operations constitute a potential harm 
to the patient and when a potential good? 

How can dental diseases be prevented? 

To what extent are degenerative diseases the direct effect and 
result of dental disease? 



34 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

Why do organs and tissues cease to properly function and 
ultimately degenerate, thereby wrecking the whole life either by 
premature death or what is often worse, a long protracted and 
agonizing death? 

Why is it that in about ninety per cent, as estimated by high 
authorities, the final blow is struck by an organism, usually the 
streptococcus, even in patients with such involvements as pneu- 
monia, and where do the streptococci come from? 

These are some of the questions that we have undertaken to 
answer in these volumes. 






CHAPTER I. 

CAPABILITIES AND LIMITATIONS OF THE 
ROENTGEN-RAYS. 

PROBLEM: To what extent are the Roentgen-rays capabh 
of disclosing dental infections? 

INTRODUCTION. 

Since it is not my intention in this volume to furnish an his- 
torical review and criticism of the literature on the many topics 
that will be presented, both because it would be beyond the scope 
of the presentation and because it would entail such a voluminous 
text that it would defeat the very purpose by its energy consum- 
ing detail and unwieldiness, I will, accordingly, make important 
references throughout the text without purporting to make an 
historical review. 

I have selected for presenting as the first problem a study of 
the efficiency of the aid in dental diagnosis which is more depended 
upon by the members of both the medical and dental profes- 
sions than any other — namely, the Roentgen-rays — and which, 
because of the almost implicit confidence of the members of the 
medical and dental professions, the members of the laity have 
come to look upon as being infallible and practically limitless in 
application. I have divided this first problem into three sec- 
tions: (a) An analysis of the fundamental that roentgenograms 
are capable of revealing the presence of infection; (b) That the ap- 
parent extent of the absorption is the extent and volume of the infec- 
tion or focal area; and (c) That an area of absorption, if present, 
can be disclosed by roentgenograms. 

EXPERIMENTAL AND DISCUSSION. 

A review of the literature of the past and present regarding the 
applications of the Roentgen-ray for the disclosing of dental in- 
fections, together with the accepted general practice of the medi- 
cal and dental professions and the clearly defined attitude of the 
public, which has been trained by the medical and dental profes- 
sions, establishes that it is so nearly universal that it must be 

35 




^ \ 



/ 






Figure 1. Above: Rheumatic nodules in rabbits' feet. Below: Roentgenographs view of same. 

36 



CHAP i CAPABILITIES \ND LIMITATIONS OF THE ROENTGEN-RAYS 37 

considered current belief, that the Roentgen-rays will reveal the 

presence of infection; particularly if present in bone, that the ap- 
parent extent is the actual extent of bone change; and that a 
chamber or area of lesser density, if present in soft or hard tis- 
sues, will, of necessity, be disclosed by the Roentgen-rays. No 
surer evidence would seem to be possible, establishing that this 
is the attitude of mind of members of the medical and dental pro- 
fessions and laity, than that the members of each continually 
bring roentgenograms of the teeth with the full confidence that 
the reading that will be made from the roentgenograms will 
answer the question as to what should or should not be clone for 
that patient with regard to the teeth. An illustration of this at- 
titude of mind is found in the current expression that the roent- 
genogram has made possible a living postmortem. 

Our studies have included both the testing of the general prin- 
ciples on material that could be cut up and verified, and a careful 
comparison of the actual conditions as revealed at operation, with 
the apparent conditions as disclosed by the Roentgen-ray. It is, 
for example, common practice to have joints that are very badly 
swollen and with extensive involvements roentgenographed, in 
order that a proper diagnosis may be made for the patient. Fig- 
ure 1 shows a photograph of three feet and one knee joint of a 
rabbit, each one containing extensive areas of infection. The 
three feet were much swollen, and on removing the skin little sacs 
filled with pus were present, in size and shape corresponding to 
garden peas. The knee, shown in A, was enlarged and dense with 
a pulsating mass of pus which involved the synovial membranes 
and joint capsule. B shows roentgenograms of these limbs; and 
the evidences of infection, as disclosed in the photograph, are not 
such as would be suggested by the roentgenograms. 

Not succeeding in revealing the presence of pus in these cases, 
we selected tw r o very extreme cases, as shown in Figure 2, where 
the quantity of pus present was so large that it was breaking out 
of the tissue. It will be seen that the Roentgen-ray does not re- 
veal the presence or extent of these infections. 

It is very true that we are dealing here with relatively soft 
tissue, the muscle, which, compared with the bone of the face, 



38 DENTAL INFECTIONS. ORAL AND SYSTEMIC -RESEARCHES— VOL. I 








Figure 2. Very extensive purulent arthritis, which has extended beyond the joint capsules 

AND BETWEEN THE MUSCLES. NOTE: THE ROENTGENOGRAM FAILS TO DISCLOSE THE INFECTION. 




Figure 3. Comparison of the apparent with 
the actual. a and b show, roentgenographically, 
two maxillary molars. note their difference. 
a' shows the periapical granulomata attached 
to the roots of a, and b' the periapical granu- 
lomata attached to the roots of b. the zones of 
rarefaction in a and b are obscured by zones of 
condensing osteitis. 



Figure 4. A.roentgenographic 
view of the root and apical 
area of a cuspid; b, an en- 
largement of the root and 
granuloma removed from this 

AREA. 



[CHAP. I — CAPABILITIES AND LIMITATIONS OF THE ROENTGEN-RAYS.] 

39 



CHAP 1 CAPABILITIES AND LIMITATIONS OF THE ROENTGEN-RAYS II 

may be considered to be very much less capable ol differentiation, 
since the difference in density Of pus and muscle tissue may be 
said to be less different than pus and bone. We have, accordingly, 

made careful comparisons of the apparent with the actual 
conditions as they obtain in the mouth. Figure 3 is a good illus- 
tration. In A and B, we have a sample of the usual roentgen- 
ographic disclosures. It is probable that not only the majority, 
but almost the complete personnel of the medical and dental 
professions and laity, would see in the fust and second molars two 
radically different conditions of pathology. There is definite evi- 
dence of bone absorption about the apices of both roots of the 
first permanent molar, exceedingly little about the mesial root of 
the second molar, and practically none disclosed about the apex 
of the distal root of the second molar. A' and B' show the 
conditions of these roots when extracted, each having extensive 
adherent granulomata, which granulomata were larger on the 
second molar than the first, though they were not revealed by 
the roentgenogram ; and the granulomata seen on the first molar 
were very much larger than the areas suggested by the roentgen- 
ogram. Our large accumulation of evidence of this type has 
crystallized our convictions into quite definite form, as expressed 
in succeeding chapters. 

Figure 4 is another illustration. The root shown between the 
two gold crowns in A does not appear to have a granuloma; and 
yet, in B, it is demonstrated that this root when extracted had, 
notwithstanding its appearance in the roentgenogram, a very 
large granuloma. It may be argued by some that, if roentgeno- 
grams were taken from other directions or with rays having other 
degrees of penetration, these would be disclosed. Figure 5 shows 
an effort to disclose the presence or extent of pockets of periodon- 
toclasia about a tooth. A and B show two different angles; yet 
neither the presence nor extent of the gingival and periodontal in- 
fection is definitely established. In C, some flexible gutta-percha 
points were placed in the gingival pockets and roentgenographed, 
which quite readily disclose much additional information. D is a 
roentgenogram of the extracted tooth to show the difference in 
the density of the root surrounded by pus and the adjoining roots. 
It should be noted that not even the roentgenogram shown in C 
discloses the actual condition ; for, at the time of removal of the 
tooth, it was revealed that there was a continuation of the pocket 
through into the antrum. 

It is common practice to determine the efficiency of root fillings 
as they exist in the mouth by means of the Roentgen-ray, on the 



42 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




Figure 5. Roentgenographic studies of periodontoclasia: A and B, different 
angles; C, with flexible gutta-percha points; D, extracted tooth. 




Figure 6. Comparison of roentgenographic view of teeth with the photo- 
graphs of same when extracted. 



CHAP : CAPABILITIES AND LIMITATIONS OF I III-. ROEN fGEN-RAYS 13 





Figure 7. Comparison of roentgenographk and photographk 
views of an incisor. 




Figure 8. Photographic view of external oblique ridge over second and third 
molars. which cast the shadow shown in figure ". 



44 DENTAL INFECTIONS. ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




Figure 9 shows a radiopaque area over roots of second 
and third molars. (see figure 8. ) 




Figure 10. A roentgenographically innocent tooth, but actually a very 

DANGEROUS ONE. 



CHAP. 1 CAPABILH IES U^D LIMITATIONS OF I ill ROENTGEN-RAYS 15 

presumption that the root filling is more opaque than the tooth 
structure, and being within the tooth structure, its true position 
and extent can be revealed by the Roentgen-ray. We have made 

main- studios to determine this. A typical illustration will be 
seen in Figure 6, in which A and B show two different angles oi 

the molars and bicuspids in a case under study. You will note 
that there is little evidence of the actual condition revealed in 
this case. There was an extensive cyst over the bicuspid and 
molar, only slightly outlined in the roentgenogram. Its presence 

and nature were established by microscopic examination of 
aspirated material. D and E show different photographic views 
of the molar from which both buccal roots had been absorbed. 
and one of the root fillings is seen projecting and exhibits a con- 
dition which is not revealed by the Roentgen-ray. F shows a 
photographic view of the second bicuspid from which the apical 
third was absorbed and its root filling extending considerable 
distance beyond the tooth; and yet. in the roentgenograms there 
is no evidence of this condition. It would appear in both A and B 
that the root filling is short of the apex. This case is referred to 
again in the chapter on Dental Cysts. 

Figure 7 shows in A. roentgenograms of two central incisors, 
neither of which was tender to percussion or had given evidence of 
sensitiveness, one of which did not respond to temperature change 
when a search was made for a cause for rheumatism. It had a 
putrescent pulp and a very serious periapical involvement, with- 
out evidence of same in the roentgenogram. C shows the apical 
third of this root from which the pericementum had been 
destroyed, apparently for years, so that it was greatly dis- 
colored; and yet, the lamina dura and bone adjacent to the 
alveolus were found to be in almost normal position though not 
in normal condition, notwithstanding it is not a condition that 
is revealed by the Roentgen-ray. This is discussed in the next 
chapter. 

Figures 8 and 9 show a photograph and roentgenogram of a 
mandible to illustrate the influence of the external oblique ridge 
in superimposing a dense bone, i varying greatly in different in- 
dividuals), over the apices of molar roots, which modifies in large 
measure the roentgenogram as shown but only in part accounts 
for the condition as seen in Figure 3. While Figures 8 and 9 
illustrate the effect of an interposing dense bone, our studies 
show that frequently the interposing hard substance may be the 



46 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




Figure 11. A comparison of the roentgenographic and photographic studies 
OF TEETH. Note the absence of evidence of acretions in the roentgenograms 

OF THE TEETH in Sl'tlt ABOVE, AND AFTER EXTRACTION IN THE CENTER. WHICH ARE VERY 
CLEARLY REVEALED IN THE PHOTOGRAPHS OF THE SAME AFTER EXTRACTION, SHOWN BELOW. 



CHAP I ( \l'\mi I riES UMD LIMITATIONS OF ill! ROENTGEN-RAYS 

tooth itself, or another root of the same tooth, as illustrated in 
Figure 10, in which the roentgenogram of the centra] incisors is 
shown. There is exceedingly little difference in the condition dis- 
closed about the apices of these two centrals; yel one is vital and 
the other non-vital, as disclosed in the search for a cause for a 
very acute and severe attack of rheumatism which had been re- 
curring with increasing frequency and severity; and at this time, 
the patient could scarcely walk and was compelled to shuffle the 
feet along with almost no use of the feet and ankles. Thermal 
and electrical tests revealed the fact that the pulp was apparently 
non-vital in the central incisors showing the small filling. The 
color of both teeth was practically identical. The patient pro- 
tested against losing the tooth. The reason for extraction and 
not root filling will develop in later chapters. The proof of local 
infection, secured for diagnosis, was established by aspirating 
from over the root and comparing the blood count with the 
patient's general circulation, which disclosed a higher leucocytic 
invasion than normal. The extraction of the tooth revealed a 
lateral canal with a small area of absorption at about the junction 
of the middle and apical thirds, which, being situated on the ex- 
ternal surface of the root, was in line with the tooth and therefore 
not disclosed by the Roentgen-rays. The opaque tooth hid the 
area of absorption which was very slight. This is shown in C 
with a metal point placed in the lateral foramen. B of this figure 
shows a knee and ankle very profusely bathed in pus coming from 
the synovial sacs of the knee and ankle joints of a rabbit which 
was inoculated with the culture from this supposedly normal and 
harmless tooth. 

It is quite remarkable how little difference the Roentgen-rays 
will reveal in the structure of a vital and non-vital tooth. Nor 
do we look for a change in the tooth structure as a rule. The 
change is expected to be in the supporting alveolar bone. Many 
teeth, however, carry depositions and incrustations, or zones of 
absorption, without any evidence of the same in the roentgeno- 
gram. An illustration of this will be found in Figure 11 which 
shows different views of a cuspid and two laterals by each method, 
roentgenographing and photographing, the latter both before and 
after extraction. The corresponding photographic views of the ex- 
tracted teeth are shown in both photographs and roentgenograms. 
There is little suggestion in the roentgenograms of the extensive 
structural changes which are disclosed in the photographs. 



48 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 










Figure 12. A, a high angle view of the upper molars. 

C, THE APPEARANCE OF THE EXTRACTED TOOTH. 



B, A LOW ANGLE. 



One of the most common defects met with is the securing of 
roentgenograms of the upper molars because of the anatomical 
complications. The hard palate is often too low to permit the 
film to be placed laterally to the tooth, thereby requiring it to be 
placed at an angle if the apices of the roots are to be secured. 
While this condition can be partly overcome by retaining the 
lateral parallel position, there is a distinct limitation which re- 
quires the angle of incidence of the rays to be raised, which con- 
dition brings the malar bone into the field. This frequently casts 
a shadow of opacity, partially or entirely masking the details of 
the bony structure about the apices. Such a case is shown in 
Figure 12. In this instance A shows a roentgenogram brought by 
the patient from an excellent radiographer who, working with a 
group who had been looking for a cause for a neuritis in this 
patient, advised her that there was no contributing involvement 
of the teeth. B shows a different angle of these molars, disclosing 
a distinct area of radiolucency about the apices of the second 
molar. C shows an enlarged view of this tooth with its very ex- 
tensive granulomatous mass, which evidences the possibility of 



CHAP. I t. \ I'M Ml 1 riES \ND LIMITATIONS ( IF I 111 ROEN fGEN RA^ S 1!> 




u 



50 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES-VOL. I 

there being an extensive involvement of periapical tissue without 
its being disclosed by the Roentgen-ray. 

It is not an uncommon condition for the largest of the multiple 
foramina of the tooth to be on the side of the root at any point, 
often about half way between the apex and the gingiva. In these 
cases there may be an extensive zone of rarefaction laterally to 
the root, which, because of the physical conditions, cannot be 
disclosed by the Roentgen-ray. Two of such cases are shown in 
Figure 13 in A and D. In D, the roentgenogram is shown above 
the tooth, and the photograph of the tooth shows the large granu- 
lomatous mass attached to the root. But this condition is more 
frequently found on incisors; and if the lateral foramen chances 
to be either labially or lingually from the pulp, instead of mesially 
or distally, neither the foramen nor the granulomatous mass form- 
ing about its exit will be revealed. Such a condition is shown in 
Figure 13-A. In this case the patient was suffering from acute 
rheumatism, and the examination of his teeth, roentgenograph- 
ically, did not disclose this condition, which we have shown else- 
where to be significant from cultural and animal inoculation 
tests. The chamber of rarefaction was present but could not be 
disclosed, owing to its position, it being in the path of the root, 
which prevented the Roentgen-rays from disclosing it. Much as 
a dog would not be seen when it was lying behind a tree, except 
that in the roentgenographic work the obstruction of the tree 
is as complete whether the zone of rarefaction is between the 
tooth and the foramen, or between the tooth and the source of 
Roentgen-ray. 

In Figure 13-B we have an illustration of the difference in the 
size of the area of rarefaction occupied by the granuloma, and its 
apparent size in the roentgenogram. I do not mean that this 
picture of the granuloma corresponds with the picture as shown 
in the roentgenogram, for in the former the tooth and granuloma 
are purposely enlarged. By making the proper correction for 
this change in size of the tooth, these still do not have the ex- 
pected evidence in the roentgenogram. This is the more striking 
since the granuloma, as shown, is in relatively correct size, having 
shrunken considerably, due to exposure to the air, between the 
time of its extraction and its being photographed. This condi- 
tion is a very common one which we will discuss later in the rela- 
tionships between condensing osteitis and rarefying osteitis. 

In Figure 13-C we have a condition somewhat similar to that 



CHAP. ] CAPABIL1 riES \ND LIMITATIONS OF I ill-. ROEN ["GEN RAYS 51 

in D; and while it is from a case of extensive periodontoclasia, its 
structural relationship to the tooth to which it is so closely ad- 
herent with a distinct separation from the surrounding connective 
tissues, except through the peridental membrane, only a small 
portion of which has remained vital, strongly suggests that this 
granulomatous mass is directly related to the tooth and products 
coining from it. 

In Figure 14. I have undertaken to show a group of such con- 
ditions, with the teeth shown approximately normal size for com- 
parison with the roentgenograms; and it will be noted that there 
is very little evidence of the existence of the extensive periapical 
absorptions such as are necessary to accommodate the large 
granuiomata present. Indeed, it will in many of them be difficult 
without experience to determine which tooth in the roentgeno- 
gram is the one involved. In A, it is the first biscuspid ; in B, it is 
the first molar; in C, it is the lateral; in D, it is the third molar; 
and in E, it is the second molar. 

Since the roentgenogram is only a shadow, the angles of inci- 
dence of the rays to both the tooth and the photographic plate 
receiving the impression, have all significance. We are all familiar 
with the increasing length of our statures as we walk away from 
the sun in the evening, or the shortening of our shadow toward 
noonday; and, indeed, the length of this shadow 7 has constituted 
one of the most important means for reckoning time, since the 
height of the object causing the sun's shadow was known, or 
could be determined. But in this field we find ourselves reversing 
the process and undertaking to determine the length of the object 
causing the shadow, all of which can, of course, be accurately 
done only when we know these angles of incidence. This is 
illustrated in Figure 15, in which I have shown three photographic 
views of the same tooth, which is an upper biscuspid and has a 
protruding root filling. In the first view from the left, the rela- 
tion of the root filling to the apex is shown laterally, which is the 
mesiodistal position. When the same tooth is viewed from the 
buccal position, some of the root filling is covered because of the 
fact that it does not leave the root at the most dependent point ; 
and since it is between the extension of the root and the source of 
ray, the shadow of part of the exposed root filling is obstructed 
by the lingual aspect of this root. But this view is taken at nearly 
right angles to the long axis of the root, a position that is impos- 
sible in this patient's mouth because of the low palate; and when 
the tube is raised sufficiently to have the shadow of the tooth 
fall upon a film that could be placed in the mouth, so much of the 



52 DENTAL INFECTIONS. ( )RAL AND SYSTEMIC -RESEARCHES VOL. I 




Figure 14 Comparison of the roentgenographs 

AND PHOTOGRAPHIC APPEARANCES OF EXTRACTED TEETH. 



CHAP. 1 CAPABIL1 HES VND LIMITA1 IONS OF I ill. ROEN fGEN R v. 




Figure l.>. Different views of the bicuspid rout shown in Figure 6 
A. SIDE VIEW, RIGHT angle; B, lateral view, RIGHT AM. I E; C, LATERAL view, 
forty-five degrees. 







Figure 16. Relation of angle of incidence of rays to tooth and film 
planes: X(). 1 AT RIGHT ANGLE to plane of tooth; No. 2 AT right angle to plane 

OF FILM: Xo. 3 AT RIGHT ANGLE TO A PLANE HALF WAY BETWEEN PLANE OF FILM AND 
PLANE OF TOOTH. THE CORRECT POSITION TO MAKE TOOTH APPEAR THE PROPER LENGTH. 



54 DENTAL INFECTIONS, ORAL AND SYSTEM IC^RESEARCHES— VOL. I 

exposed root filling is in line with the lingual aspect of this root, 
that it gives the appearance of only a short perforation. This is 
shown in the view to the right, Figure 15. Unfortunately, this 
is not an uncommon or unusual condition, for it is one that ob- 
tains very frequently. 

I have published, previously, 1 an article on the relationship 
between the angle of incidence of the rays and the apparent size 
of the shadow. In Figure 16, 1 have reproduced this drawing and 
the roentgenograms that were used originally to illustrate it. In A 
it will be seen that a low angle of the ray at right angles to the 
long axis of the tooth, but with the plane of the film placed at an 
oblique angle to the plane of the axis of the tooth, makes an 
elongated shadow of the root of the tooth, illustrated in the 
roentgenogram also taken at this angle. B shows the same case 
photographed at an angle high enough to be at right angles to 
the plane of the film, in which case the tooth is foreshortened, as 
shown in the roentgenogram of the same case taken at this angle. 
C shows the correct position for obtaining the shadow of the 
tooth of the same total length as the length of the tooth, to obtain 
which the rays must fall at right angles to a plane which is half 
way between the plane of the tooth and root, and the plane of the 
film, as shown. C shows the roentgenographic appearance of the 
same case as A and B when so rayed. 

SUMMARY AND CONCLUSIONS 

From these few illustrations selected to demonstrate different 
conditions, it is apparent that the problem is not so simple as it 
is generally understood to be. While the analyses of the new 
problems disclosed by this study are made in detail in subsequent 
chapters, in general, it is demonstrated in these and a very large 
number of cases not included here, that the original premises 
a, b, and c, as stated, do not present the facts; and that these 
should be stated in the light of our present knowledge about as 
follows: 

(a) That Roentgen-rays will not necessarily 
reveal the presence of infection, either in soft tissue 
or in hard; (b) That the apparent extent of the ab- 
sorption is not necessarily the actual extent of the 
absorption; and hence, even assuming that the ex- 
tent of the infection is the extent of the absorption, 
is not the extent of the infection; and (c) That an 
area of absorption may be present and not be dis- 
closed by the roentgenogram, nor are conditions 
and relations necessarily as they appear to be. 

1 See bibliography. 



CHAPTER II. 
THE NATURE OF THE ORGANISMS INVOLVED. 

PROBLEM: Is the danger from a denial infection prima- 
rily dependent upon the invasive quality of the organisms 
involved; or, otherwise stated, is it true that dental infections, 
when they occur at the apices of roots, are produced by the 
invasion of thai area by organisms from the mouth which 
enter that tissue through the open pulp canal; and that the 
question of danger from such an infection is dependent upon 
the invasive qualities of that organism? 

EXPERIMENTAL AND DISCUSSION 

While many workers, besides ourselves, in the field of the bac- 
teriology of dental infections, have called attention to the fact 
that streptococci are usually present in root end infections, it is 
generally understood by the members of the dental and medical 
professions that, whatever the classification of the organism, the 
injury it will produce has to do with the particular kind or strain 
of organism involved. Those most familiar with the literature 
are familiar with the fact that the organism involved is now 
generally understood to be a streptococcus. 

The research herewith reported, which has covered many years, 
has centered about the following phases of the problem : 

(a) What are the morphological characteristics of the or- 
ganism? 

(b) What are the biological characteristics of the organism? 

(c) What is the relationship between the morphological and 
biological characteristics and their local and systemic tissue ex- 
pressions? 

(d) To what extent are the organisms influenced by variations 
in the pabulum, or culture medium, in which they grow? 

(e) Are the organisms capable of producing specific toxic sub- 
stances and, if so, under what conditions? 

(a) What are the morphological characteristics of the 

organisms? 
To determine these factors, we have made a study of the or- 
ganisms secured from the various dental tissues involved, and 

55 



56 DENTAL INFECTIONS. ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

have compared them with the strains recovered after their injec- 
tion into various types of experimental animals. We have found, 
in general, that in approximately 98 per cent of instances, the 
dominating organism present appears as a coccus, growing in 
diploic and chain form, chiefly short chain; and that where the 
organism is taken from dental lesions, and inoculated into experi- 
mental animals and recovered from their tissues, in one series 
taken from forty different sources and inoculated into about one 
hundred animals, the organisms as recovered from two hundred 
lesions in those animals had the same morphology except that 
there was an increased tendency to grow in short chains and in 
diploic form until regrown in artificial media. In the histological 
sections of the tissues from these lesions, the organisms were seen 
almost entirely in diploic form. In later chapters I have 
discussed the teeth as carriers of infections for contagious and 
infective fevers. 

In a large number of cases the culture injected, as grown from 
the original focus, contained in addition to this coccus other 
bacterial forms, chiefly a short bacillus and staphylococcus, also 
in spiral forms. In a few instances we recovered from tissues by 
cultural methods the staphylococcus as well as the diplococcus, 
and in less than 2 per cent staphylococcus only. As we now view 
this work, we do not feel sure that the diplococcus was not present 
in those cases where we did not identify it, having come to recog- 
nize that it is quite exacting in some instances regarding oxygen 
tension and hydrogen ion concentration; and where both organ- 
isms grew out, the diplococcus may have been overgrown. We 
do not question the presence of the staphylococcus, but we are 
not certain of the absence of the diplococcus. It is significant 
that animal passage generally destroyed all organisms except the 
diplococcus. Our recent methods of culturing are showing the 
presence of streptococci or diplo-steptococci as one or the only 
organism in infection of the tooth structure. 

(b) What are the biological qualities of the organisms 

involved? 
These have been determined by their reactions on culture 
media and animal tissues. We have found many varieties of the 
streptococcus. Figure 17 is made from sixty-seven successive 
cases and shows that many types of the streptococcus may be 
found in dental lesions, chiefly the following: faecalis, ignavius, 
salivarius, infrequens, mitis, non-hsemolyticus I, non-haemolyt- 
icus III, hsemolyticus I, subacidus, and pyogenes. The column 



CHAP. II fHE NATURE OF THE hum, wisMs INVOLVED 






marked "Per cent" shows the percentage of these various varie- 
ties occurring in the total number included in the study. The 
ratio or percentage of these to each other is expressed graphically 
by the solid lines to the left under "Graphic Expressions." This 
shows strikingly the very large percentage of faecalis. 



RELATIVE PREVALENCE OF DIFFERENT STRAINS 


•Type of Streptococcus 


*. 


Graphic Impressions 


Fecahs 
Ignavius 

Salivarius 
Infrequens 
Mitis 

Non-Hemolyticus I 
Non-Hemolyticus III 
Hemolyticus I 
Subacidus 
Pyogenes 


IH 

9 

?'■> 
3 " 
3 
3 

l',> 
4'-, 




1 lllll I.I 



* (Note— Streptococcus viridans is the group name of non-hemolyzing streptococci 
producing a narrow green zone when grown on blood agar) 

Figure 17. 



BACTERIAL CLASSIFICATION IN RELATION TO TISSUE AFFECTED. 












to 

3 


CO 

3 










CO 














u 


•_> 










CJ 














>, 


*-> 
>> 


en 








cu 


CU 
CJ 


Type 

of 
Lesion 

in 
Patient 


en 

3 

> 
N 

C 


co 
3 
'C 
> 


co 

c 

V 

3 
O* 
V 
u 

"a 

i— i 


C/3 


O 

E 

<u 

X 

c 
o 
Z 


O 

S 

CU 

X 

c 
o 
2 


3 
ej 

4J 

"o 

n 

01 


en 

3 

•o 

'u 
ca 

J3 
3 
X 


CO 

CU 

C 
<u 

be 
O 

cu 


CO 

"re 

CJ 

cu 


c/3 

cu 
bag 

CO 

*-> 

c 

cu 

CJ 

u 


u 

o 
o 




s, 


S, 


in 


c/) 


C/) 


c/) 


S) 


in 


C/) 


CO 


CL, 


K 


Rheumatism 






2 




1 


1 








7 


11 


7 1 


Heart 




















2 


3 


1.3 


Nerves 




1 


3 


4 


2 


1 


2 




3 


21 


33 


24 05 


Lassitude 






2 


1 












11 


17 


9 1 


Internal Organs 




1 


1 


1 












8 


13 


7 1 


Special Tissues 


1 




3 


1 




3 








7 


11 


9 7 


No Lesions 
















1 




7 


11 


5 2 



Figure 18. 



58 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

We have failed completely to establish a relationship between 
the various strains of streptococci and particular types of tissue 
lesions in the patient, and the results of animal inoculations have 
been similar, in that the particular types or strains of streptococci 
that were introduced, did not of necessity produce a particular 
type of lesion in animals, although various strains were found to 
reproduce in animals particular lesions possessed by the patient 
from whom they were taken. There was also no constant rela- 
tionship between the biological properties, as expressed in sugar 
fermentations and the expressions in animal tissues. 

(c) What is the relationship between the morphological 

AND BIOLOGICAL CHARACTERISTICS AND THEIR LOCAL 
AND SYSTEMIC TISSUE EXPRESSIONS? 

If, as has been so generally supposed, the particular type or 
strain of invading organism determined the tissue reaction and 
elective localization, we should expect that a careful study of the 
biological properties, such as sugar fermentation, would have a 
direct relationship to the type of tissue involved in a particular 
individual. To determine this we have made a careful study of 
the percentage of instances in which the various strains of the 
streptococcus were present, and have noted the particular type of 
tissue that was involved in that patient's body. The result of 
this study is strikingly shown in the chart in Figure No. 18. It 
will be seen, not only that the localization in the various structures 
is not limited to a particular type, but, on the contrary, the vari- 
ous tissues have been invaded indiscriminately by the different 
varieties of streptococcus. For example, the nerve tissues were 
invaded by all but two of the ten principal varieties of strepto- 
cocci. 

By expressing this relationship in percentage, we have an op- 
portunity to compare the appearance of each of these varieties 
with its appearance on the basis of chance, assuming there was no 
localizing quality characteristic of each variety. This is shown 
for S. Fsecalis under the column, the second last to the right, 
entitled "Percentage S. Fsecalis." For this study a group of one 
hundred localizations was used; and hence, for any one tissue the 
total number of appearances of a particular variety, say Fsecalis, 
in proportion to the total number of appearances will give us the 
percentage. For example, in rheumatism there were 7 instances 
of Faecalis out of a total of 63 appearances of Faecalis. The per- 
centage of appearances as rheumatism of Fsecalis was 11 per 
cent. The ratio of chance, were there no elective localization, 



CHAP 11 rHE NATURE OF fHE ORGANISMS INVOLVED 



59 



would give on this basis 7.1; whereas, the actual appearance, as 
shown, was 7. For heart, the ratio of chance will give Faecalis 
1.3; the actual appearance was 2; for nerves, 24.05 and 21; for 

lassitude. 9.1 and 11; internal organs 7.1 and 8; special tissues 
9.7 and 7; no lesions. 5.2 and 7. It will therefore be seen, that 
there is so close an adherence of the actual appearance to that 
which should be expected on the basis of chance, that we must 
conclude that the elective localization qualities are not dependent 
upon inherent biologic properties of the variety of the streptococcus 
involved. This is a matter of exceeding great importance 
since it shifts the burden of fundamental responsibility from 
the bacterium to the host, as will be clearly demonstrated 
later. 

ID) TO WHAT EXTENT ARE THE ORGANISMS INFLUENCED BY 

VARIATIONS IN THE PABULUM, OR CULTURE MEDIUM, IN 

WHICH THEY GROW? 

The next problem namely, to what extent are the organisms 
influenced by the nature of the pabulum or culture medium in 
which they grow must throw direct light upon this quality of 
accommodation of the organism. To determine this, several 
series of studies were made to ascertain the ability of streptococci 
to adapt themselves to their environment. These are shown 
graphically in Figures 19, 20, 21 and 22. For this study, strains 
were planted in a culture medium in which they were known to 

FORMALIN 



















o 


o 














c 


o 


-<* 


1 




o 


o 


o 


o 

CC 


o 


o 

<M 


CO 


CO 


a-. 


CM 
<T. 


00 

CO 




<o 


CM 


-* 


CM 


LO 




o 


o 


o 


1—i 


«3 


CM 




r~* 


co 


'X> 




esi 


LO 




CM 


^r 


00 


i 


CO 


1-3 














1+ 


4 + 


4 + 


4 + 


4 + 


4 + 


2-5 












3+ 


4 + 


4 + 


4 + 


4 + 


4 + 


4 + 


2-6 




— 






4 + 


4 + 


4 + 


4 + 


4 + 


4 + 


4 + 


2-7 





— 





4 + 


4 + 


4 + 


4 + 


4 + 


4 + 


4 + 


4 + 


2-8 





— 


— 





4 + 


4 + 


4 + 


+ 


+ 


+ 


+ 


+ 


2-9 





— 


— 





4 + 


4 + 


4 + 


+ 


+ 


+ 


+ 


+ 


2-10 





— 


— 


4 + 


4 + 


4 + 


4 + 


+ 


+ 


+ 


+ 


+ 


2-11 





■ — 


— 


4 + 


+ 


+ 


+ 


+ 


+ 


+ 


+ 


+ 


2-13 





— 


2 + 


4 + 


+ 


+ 


+ 


+ 


+ 


+ 


+ 


+ 


2-17 





— 


4 + 


+ 


+ 


+ 


+ 


+ 


+ 


+ 


+ 


+ 


2-20 





— 


+ 


+ 


+ 


+ 


+ 


+ 


+ 


+ 


+ 


+ 


2-24 





— 


+ 


+ 


+ 


+ 


+ 


+ 


+ 


+ 


+ 


+ 


2-28 





— 


+ 


+ 


+ 


+ 


+ 


+ 


+ 


+ 


+ 


+ 


3-22 


+ 


+ 


+ 


+ 













+ =weak growth. 
4+ =full growth. 
— = negative growth. 



Figure 19. 



60 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

grow well, and to this medium, toxic substances were added to 
determine the point at which the toxicity would prevent the 
growth of the organisms. It was found that by taking the 
dilution just greater than would entirely inhibit the growth 
of the organism and maintaining the organisms in that con- 
centration, they presently acquired a quality of growing 
quite readily in the presence of that poison; and by 
replanting, it was found that they would soon permit a new in- 
crease without seriously handicapping them. In this way, by 
slowly but continually increasing the concentration of the poison, 
it was found possible to grow streptococci taken from dental 
infections in one to three hundred twenty of formalin; 
whereas growth of this strain was inhibited by one to five 
thousand in its original strength. Similarly, it was found that 
these varieties would accommodate themselves to almost any 
irritant, even growing luxuriantly in twenty per cent alcohol (See 
Figure 21), one to ten iodoform saturated in alcohol (Figure 
20), one to eight hundred phenol (Figure 22), one to two 
hundred thalium sulphate (Figure 22). 

This has a very wide bearing upon our whole problem and 
suggests the answers to many questions. For example, we have 
often asked why it is that teeth that had been root -filled with 
iodoform, and in which the odor of iodoform was still persistent 
after years of time, would show an abundant growth of strepto- 
cocci in the midst of the root dressing highly fragrant with iodo- 
form. The organisms had very clearly accommodated them- 
selves; for in our tests of feeding this chemical to streptococci, we 
found that they would ultimately grow in saturated aqueous 
solutions of iodoform. 

Under another chapter we will discuss the reasons for the 
efficiency of iodoform in the treatment of wounds. 

In our studies of the characteristics of the organisms growing 
in infected teeth, extending over several years, we have found 
that with an increased knowledge of the nature of the organisms 
and their power of accommodation and adaptation to their en- 
vironment, they come to take on quite relatively stable, or well 
defined, characteristics, with regard to the kind of culture medium 
in which they will grow. With our increasing knowledge we 
are finding that the data accumulating show a quite definite 
per cent of teeth which are proven by positive culture to be in- 
fected, which means that whereas all positive cultures, 
of course, are positive, the absence of growth is not nec- 
essarily an evidence of the absence of an infection in the material 



CHAP 11 rHE NATURE OF THE ORGANISMS INVOLVED 61 

IODOFORM SATURATED IN ALCOHOL 



























o 






o 


3 








o 


o 


- 




s 


CM 


— 


M 


10 


O 
CM 


— 

CM 

o 




3 


jj! 


8 


t - 








cm 


— 




CO 


* 




N 


'? 




CM 






CO 




2-28 











• 


+ 


• 


+ 


+ 


+ 


1 


+ 


1 


( 


t 


+ 


f 


3-22 




+ 


+ 


• 


• 


■ 


+ 


+ 


+ 


+ 


1 


+ 


• 


+ 


1 


• 


r 



Figure 20. 



ALCOHOL 





o 


o 

CM 

+ 


o 

+ 
+ 


Q 

op 


O 

o 


Q 

o 

CM 


o 
o 
— 


s 

00 


o 


o 
o 

CM 

CO 


o 
o 

IC 

4 + 
4 + 
+ 


© 

O 

CO 

cm' 

4 + 
4 + 
+ 


in 

CM 

4 + 
4 + 
+ 


o 

CM 

4 + 
4 + 
+ 


48 hrs. 
2-11 to 13 

2-21 
2-28 
3-1 
3-22 


+ 
+ 


4 + 


4 + 
4 + 


1+ 

4 + 
4 + 

4 + 


4 + 

4 + 

+ 

4 + 


4 + 
4 + 
+ 

4 + 


4 + 
4 + 
+ 



— = negative growth 
+ = weak growth 
4+ = full growth 



Figure 21. 



PHENOL 





o 
o 


o 

CM 

• 


o 
o 


O 
8 


o 

o 

<£> 

r— < 
1 


Q 
O 
CM 

CO 


o 
o 

to 


o 
o 
oo 

cm" 


o 
o 
05 

LO 
CM 


o 
o 

N 

LO 


o 

o 

-f 

cm" 
o 


o 

00 

-1-' 
o 

CM 

i 

+ 

+ 
+ 


= 

o 
o 

+ 

+ 
+ 


8 

CM 

cr. 

00 

+ 

+ 
+ 


2-1 

48 hrs. 

2-15 

2-17 

2-24 

2-27 


— 


— 


— 


2 + 
4 + 


4 + 
4 + 


+ 

4 + 
4 + 


+ 
+ 

4 + 
4 + 


+ 
+ 

4 + 
4 + 


+ 
+ 


+ 

+ 
+ 


+ 

+ 
+ 


THALIUM SULPHATE 


2-17 
2-24 
2-27 
3-22 


— 


+ 


+ 


+ 
+ 
+ 


+ 
+ 

+ 


+ 

+ 
+ 
+ 


+ + + 
+ + 
+ + + 
+ + + 


+ 

+ 
+ 


+ 

+ 
+ 


+ 

+ 

+ 


+ 

+ 
+ 


+ 

+ 
4- 



+ 

4 + 



■ negative growth. 
= weak growth. 
= full growth. 



Figure 22. 



62 DENTAL INFECTIONS. ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

being cultured. When organisms grow in a root filled tooth for a 
long period of time, they tend to become anaerobic, and will 
frequently not start to grow in aerobic culture in less than from 
twenty to thirty days but will grow promptly under anaerobic or 
partial tension conditions. This has a very great bearing upon 
the procedures that have been advocated for the testing of teeth 
to determine when they are ready for root filling. Figure 23 illus- 
trates this condition. Two tubes are shown which were inocu- 
lated at the same time from the old root filling material of a sus- 
pected tooth. The culture made aerobically remained sterile, 
whereas the culture made anaerobically grew out profusely in 
48 hours, showing a good growth in 24 hours. In the illustration, 
the two tubes are supported in front of a white background, 
through the center of which passes a black strip. The clear 
transparent media of the aerobic culture shows the black of the 
strip through with nearly the same clearness that is seen on each 
side of the culture media, whereas the tube with the anaerobic 
culture, or rather partial tension in this case, for the organisms 
are growing in a medium covered with oil, which medium did 
not have its oxygen removed from it before inoculation, is suffi- 
ciently toxic to hide quite completely from view the black strip 
behind the tube. In subsequent chapters I have discussed the 
significance and importance of this in its various phases. When, 
however, these anaerobes are grown in a constantly increasing 
oxygen tension, they soon come to be aerobes, again illustrating 
this most important quality: namely, their capacity for accom- 
modation to their environment. 

(E) ARE THE ORGANISMS CAPABLE OF PRODUCING SPECIFIC TOXIC 

SUBSTANCES? 

There has been practically nothing in the dental literature to 
throw light upon the complicated problem of the relative impor- 
tance of bacterial invasion and the passage of the toxins produced 
by the organisms, to the tissues of the host. To determine this we 
have inoculated large numbers of animals with washed organisms 
and bacterial filtrates, using cultures from infected teeth of in- 
volved cases. The clinical symptoms will be discussed in suc- 
ceeding chapters under special headings. 

A typical illustration of the effect of the organisms upon the 
filtrate of the culture media in some cases, for all strains do not 
produce comparable toxins, is the following: A rabbit which 
was inoculated with 1 cc. of the filtrate from a culture grown 



UI\I' II 1111': NAT! RE OF THE ORGANISMS INVOLVED 



63 




Figure 23. A comparison of the aerobic and anaerobic growths of inoculations 

WITH A STRAIN TAKEN FROM THE INTERIOR OF AN INFECTED TOOTH. AEROBIC, TO RIGHT, 
COMPLETELY TRANSPARENT, NO GROWTH; ANAEROBIC, TO LEFT, HEAVY GROWTH HIDING 
BLACK STRIP BEHIND TEST-TUBE. 



from an infected tooth, died in sixteen days, having lost 35 per 
cent of its weight. On postmortem, it showed acute myocarditis, 
acute passive hyperemia of the liver and kidneys, and acute 
atrophy of muscles. The anatomical diagnosis for the cause of death 
was recorded as toxemia. We will review many instances later of 
animals dying from the effects of the toxin present in infected 
teeth, which teeth have been crushed and washed, and the wash- 
ings filtered, the clear filtrate being inoculated into the animals, 
and producing quite as striking results as the above. 

Similarly, the inoculation of animals with the washed organ- 
isms has demonstrated that very small quantities of these germs 
will be adequate in the case of many strains, to produce very 
serious structural changes with or without termination in death. 
Such a condition is illustrated in the following : Of 8 rabbits so 
inoculated, 2 died within 24 hours, 3 others within 9 days, and the 
other 3 within 13 days. The average loss of weight was 2.6 per 



64 DENTAL INFECTIONS, ORAL AND SYSTEMIC^RESEARCHES— VOL. I 

cent per animal per day, as expressed in percentage of the total 
weight. The average loss of weight per animal before death was 
18 per cent, or 203 grams. The average number of days lived 
was 7. Four of the 8 had a total loss of over 28 per cent, or an 
average of 319 grams. (See Fig. 24.) 

There is a distinct difference, as is clearly shown, in the be- 
havior of different strains which we have taken from infected 
teeth and cultured, then separated from the culture media and 
washed and suspended in sodium chloride. Of 15 rabbits so 
studied, none of which were included in the former group of 8, 
4 gained in weight, an average of 336 grams, or an average of 26 
per cent, nearly 1 per cent per day. The former group of 8 all 
died spontaneously as a result of their injections. None of this 
latter group died spontaneously, all being chloroformed. The 
other 11 of this group were chloroformed on an average of 10 days 
each, at which time they had lost on an average 10 per cent, or 
approximately 1 per cent per day. There was a wide variation 
in the amount of loss, one rabbit having lost only 1 per cent in 
13 days, whereas, with another strain with which 3 rabbits were 
inoculated, they lost 17 per cent, each in 4 days, or an average of 
4 per cent per day. In each of these groups, typical structural 
lesions were produced in various tissues and organs. 

When we compare these effects of both the filtrates and the 
washed organisms on similar dosages of organisms plus filtrates, 
or rather the organisms in the culture medium in which they have 
grown without either filtering or washing, we have found that 
3/£ to 1 cc. doses, which were usually given, produced quite different 
results in accordance with the particular strain being used. For 
example, in a group of 19 rabbits which had been so inoculated, 
and all of which were chloroformed, 7 proceeded to gain in weight, 
and 12 inoculated with other strains lost in weight. The average 
gain per rabbit in the 7 of this group was 88 grams in an average 
of 22 days, or an average of 4 grams per day. The other 12 in- 
oculated with approximately the same quantities of other strains, 
lost an average of 11 per cent, or an average of 112 grams, in an 
average of 11 days, or 1 per cent per day. When we compare this 
part of the group with those of this group which died spontane- 
ously, we find that on account of their more severe infections 
these 16 rabbits lost on an average, 18 per cent, or 209 grams in 
an average of 6 days, or 3 per cent per day, which it will be noted, 
is a much more rapid rate than in the preceding, and indicates a 



Ul\l' 11 fHE NATURE OF fHE ORGANISMS INVOLVED 






marked difference in pathogenicity of the strains. 

In a larger series of a similar study, in which L08 rabbits were 
used. 55 died spontaneously in an average of 7 days, with an 
average loss of weight of 226 grams, or 20 per cent. This, it will 
be noted, amounted to a loss per day of 2.9 per cent per rabbit. 
Of this group of 108, 53 were chloroformed. Of these. 34 were 

COMPARISON OF \\ VSHED ORGANISMS WD WHOLE CULTURES. 



A. Organisms Washed and Suspended in Sodium Chloride. 



No. in 
Group 



iVath 



I >ays 
Lived 



I oss 



Actual 



8 'Spontaneous 7 

l Chloroformed 31 

11 Chloroformed H> 



203 
119 



■ , ■ , per day 



18 

10 



2.6 

1 



Gain 



Ai-tiril 



336 



26 



', per da) 



B. Whole Culture 



7 
12 
16 
55 
34 
19 



Chloroformed 
Chloroformed 

'Spontaneous 
"Spontaneous 
Chloroformed 
Chloroformed 



22 








88 


9 


11 


112 


11 


1 






6 


20 > 


18 


3 






4 


226 


20 


2.«) 






23 


150 


11 


5 






46 








1(57 


13 



* Spontaneous deaths in Group A -35 

* Spontaneous deaths in Group B 50 

Figure 24. 

chloroformed in an average of 23 days, having lost an average 
amount of 150 grams, or 11 per cent, or ' £of 1 per cent per day 
per rabbit. Nineteen of those chloroformed, in 46 days had 
gained an average of 167 grams, or 13 per cent, and l 3 of 1 per 
cent gain per day per rabbit. 

In all of these groups there were lesions in various organs and 
tissues of the body. We will not here discuss their nature and 
their relation to the disturbances from which the patients were 
suffering, as these will be taken up in subsequent chapters. 

A typical illustration of the evidence that the host may build 
up and maintain a defensive mechanism by which the toxins are 
neutralized is found in the following experiment. A virulent 
strain which grew from an extracted tooth killed a number of 
rabbits in succession by the planting of the tooth beneath the 
skin, being thoroughly washed each time before replanting. The 
exudate aspirated from the vicinity of the tooth during the period 
while the animal was showing a vigorous defense, when injected 



66 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

through the skull of a rabbit into the brain, produced very much 
less disturbance than the same material aspirated when the 
rabbit's defense was rapidly breaking and it was nearly overcome 
by the infection. In fact, the filtrate from the material aspirated 
at the time the rabbit had a good defense, a fine Berkefeld filter 
being used, when injected into the brain of a rabbit, produced so 
little disturbance that both it and the control injected similarly 
with normal salt solution were as frisky as normals for weeks 
afterwards. And, similarly, an old culture that had become toxic 
by large quantities of dead organisms sufficient to inhibit its own 
growth, when injected into the brain of a rabbit, produced death 
in a few hours ; whereas, the same quantity and approximately the 
the same bacterial density of a freshly grown culture similarly 
inoculated produced no evidence of effect for many hours. In the 
chapter on the mechanisms of defense I have discussed this ques- 
tion from another angle, and also in the chapter on sensitizations. 

SUMMARY AND CONCLUSIONS 

(a) With regard to the matter of morphology, we have found 
that in approximately 98 per cent of cases, the organism involved 
in root canal and root apex infection, a coccus growing in diploid 
and chain form, is present, and that this organism is nearly al- 
ways the only one recovered from animal passage ; and in some 
teeth this organism, though present, grows with very great 
difficulty; and we conclude that it is present in practically 100 per 
cent of cases, even where other organisms grow out in artificial 
medium and it does not. 

(b) The biological qualities of the organisms growing in root 
end infections, as determined by their sugar fermentations, show 
ten varieties of diplococci present in one hundred cases. 

(c) The elective localization qualities were found to be re- 
lated neither to the morphology nor sugar fermentation quali- 
ties ; that various tissues were invaded in the order of chance so 
far as the different varieties were concerned. Note: This does 
not imply that the particular tissue breaking down is a matter of 
chance. 

(d) The organisms found in dental infections were found to 
have a very great power of accommodation to the influence of 
the culture medium, coming finally to grow readily in concen- 
trations of poisons by which, originally, the strain was completely 
destroyed. 



LIBRARY 
°ENTAL SCHOOL 

w.v.u. 

CHAP. II rHE NATURE OF rHE ORGANISMS INVOLVED o! 

e The organisms growing in dental infections are found to 

produce toxic substances which have very far-reaching and 

disastrous effects on experimental animals. 

We would, accordingly, summarize the role of the bacterial 

invasion in dental infection and express the fundamental involved 

therein as follows: 

Dental infections involving root canals and their 
apices and supporting structures practically always 
contain streptococci, of which, biologically, there 
are many types or strains, any one of which may be 
the important causative factor for any of the various 
types of rheumatic group lesions, regardless of bio- 
logical classification. The elective localization and 
attacking qualities are developed by the environ- 
ment and are, consequently, a factor of the soil or 
host. 



CHAPTER III. 

LOCAL ORAL STRUCTURAL CHANGES PRODUCED BY 
DENTAL INFECTIONS. 

PROBLEM: Is there a constancy in the local oral expres- 
sions of similar dental infections? 

INTRODUCTION. 

It is practically universally expected and accepted that (a) 
dental infection in bone will express itself as bone absorption, and 
(b) that similar dental infections will express themselves in the local 
tissues of the mouth approximately the same in all people. This 
group of researches has been made to determine the correctness 
of these assumptions. 

EXPERIMENTAL AND DISCUSSION. 

We are dealing here with a matter that is so fundamental that 
to suggest even a possibility that it may not be true will be con- 
sidered by many a gross presumption. This study has not been 
made to disprove but to verify, in order that a justification for our 
faith might be found, with the expectation that we would have to 
look elsewhere for the explanation for the gross confusion that 
exists. We have again two fundamental problems and two fun- 
damental sources of information : Clinical material provided by 
the patients presenting different types of lesions and conditions, 
and researches on experimental animals. 

To determine the various effects of infections on humans with 
regard to tissue reactions and their constancy in various people, 
we have only to study more intensively the clinical material that 
is available. That infected teeth have an area of absorption 
about them in proportion to the quantity and severity of the 
infection, will seem to be established by the examination of the 
available diagnostic reports made upon almost any set of dental 
roentgenograms. 

68 



cHM'.lll LOCAL CHANGES PRODUCED B^ DENTAL INFEC flONS 69 




Figure 25. Illustrations of diffkrent types of reactions involving apices of roots and 
their supporting structures. 

When we compare the roentgenograms made from similar 
conditions in a large number of individuals, we find, contrary to 
the presumption just made, very marked variations in the re- 
actions from similar dental infections. Assuming that the amount 
of infection involved in the entire quantity of a putrescent pulp 
in either a central or lateral would be a similar and therefore com- 
parable quantity to compare in another case, we have compared 
typical conditions as roentgenographically expressed and find 
such a condition as is illustrated in Figure 25. This shows in A- 1 
a right central for one patient and a right lateral for another in 
B-l, each showing very extensive areas of absorption. In A-2 and 
B-2 we show similar teeth from two other patients, which have 
comparable quantities of infection but which show almost no 
absorption about the apices. These are all of long standing and 
are typical of large groups of individuals. 

It may be argued that the pulps of teeth may represent other 
factors and forces which we do not understand, and that therefore 
these conditions are not comparable as to quantity of infection, 
etc. We have, accordingly, added as A-3 a molar root and the 




Figure 26. A degenerative arthritis of a rabbit's femur, with normal above. 




Figure 27. Proliferative arthritis of a rabbit's knees with normals to right. 

70 



CHAP. Ill LOCAL CHANGES PRO! lUCED BY DENTAL INFECTIONS 71 

structures beyond it showing very extensive absorption, in which 
one root is apparently nearly filled, the other partially so. In 
comparison with this we have shown in B-3 a molar tooth with 
apparently little or no root filling and a very little absorption 

about the mesial root and practically none about the distal root. 
Culturally, practically all these pulp canals have been demon- 
strated to be infected by the same type of germ: chiefly adip- 

I0COCCUS in fresh smear taken from the pulp chamber, but grow- 
ing also in streptococcal form in liquid media. If, as has been 
quite universally accepted, all individuals react locally approxi- 
mately the same, then the conditions found in A and B of Figure 25 
will, of necessity, be related to the type of invading organism. 
The chart in Figure 18 of Chapter 2, Problem 2, "The Nature of 
the Organisms Involved," illustrated that no constancy has been 
apparent in the type of streptococcus found in different types of 
lesions. In the consecutive culturing of several thousand teeth 
from over a thousand individuals, which had been diagnosed as 
being infected, practically all were found to be so; and the type of 
tissue reaction found seemed clearly to be related to some factors 
other than the type of organism. The chart in Figure 17 of 
Chapter 2 shows graphically the relative number of different 
types of lesions produced by the different strains of streptococcus, 
and shows the relationship to be approximately that of chance 
and not dependent upon sugar fermentation qualities. If the 
difference in general structural change in Figure 25, A and B,is not 
due to the lesions being produced by different biological strains 
of streptococci, it immediately suggests that either various strains 
may take on the ability to produce these two different types of 
reactions, or these reactions may be related directly to differing 
qualities in the host. 

Figures 26 and 27 show similarly two distinctly different typesof 
reactions in the bones of rabbits. In Figure 26, we have extensive 
absorptions of the head of a femur, which is shown in comparison 
with its own mate of the opposite side, and two normals 
shown just above it. In Figure 27, the organism has produced an 
entirely different type of reaction; in this case, a deposition of 
lime salts instead of a rarefaction. Greatly enlarged knee joints 
are shown to the left and, for comparison, two normals shown 
beside them to the right. Since different rabbits inoculated with 
this culture produced the same type of reactions in bone tissue, 
we assume that the characteristic resided in the organism at this 




72 



CHAP. Ill LOCAL CHANGES PRODUCED BY DENTA1 INFECTIONS 73 

time and not in the host. When we compare the reaction in the 
rabbit with the reaction in the patient from whom the organism 

was taken, we find that in the latter case it was from a man suffer- 
ing from deforming arthritis, with such extensive depositions in 
his spine that lie could scarcely bend or rotate from his head to 
his hips; and the roentgenogram of his spine, shown in Figure 28, 
and discussed in detail in Chapter 64 shows marked spinous pro- 
duction as do also the roentgenograms of the spines, bones, hips, 
etc., of the rabbits inoculated with that culture, shown also in 
the same figure. The source of the culture from which the in- 
oculations were made producing the lesions shown in Figure 2(i, 
was a patient having marked nervous system disturbances 
without arthritis. 

In Chapter 2, Problem 2, "The Nature of the Organisms," 
we have found that the qualities of the organisms, particularly 
that of growth, will be determined by the qualities of the culture 
medium, that they have the capacity to adapt themselves to their 
environment through a very wide range. This is also illustrated 
by the following : A strain which produced heart lesions in 93 per 
cent of a group of thirty rabbits inoculated with a twenty-four 
hour growth, produced heart lesions in only 10 per cent of rabbits 
when the organism was grown on artificial media for seventeen 
days. 

Many of the researches reported in various chapters illustrate 
that, the organisms taken from different teeth of the same patient, 
produced when in the patient, similar local tissue changes, and 
when inoculated into rabbits produced similar types of bone 
change systemically to those suffered by the patient, as illustrated 
in Figures 27 and 28. These many studies suggest that the host 
determines in large measure the characteristics but not the bio- 
logical type or classification of organism; and the nature of the 
tissue change which accompanies the presence of the organism 
and also determines that there is some difference, in most if not 
all patients, in the local tissue reactions related to the quantity 
of local infection, seems evident; but that the former is a direct 
measure of the latter, regardless of the characteristics of the host, 
is studied in the following experiments. 

Results of these studies should be compared with the 
data developed in the researches presented in Chapter 2, 
"The Nature of the Organisms Involved." 



74 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




Figure 29. Progressive views of the bone about the second bicuspid of a patient with deforming 
arthritis over a period of twenty-two years. note extensive condensing osteitis in c, displacing 

RAREFYING OSTEITIS IN A, FOLLOWING TREATMENT AND REFILLING OF ROOT, WHICH CONDENSATION DISAPPEARED 
AFTER EXTRACTION. TOOTH AND BONE BOTH INFECTED. 




Figure 30. Showing similar lack of reaction about several involved teeth of same patient. 



CHAP. Ill LOCAL CHANGES PRODUCED B\ DENTA1 INFECTIONS 75 

Note: It will seem like a paradox or contradiction when I 

haw said that the culture medium rather than the organism 
determines the type of tissue involved in the elective localization 
processes and then state that the lesions produced in the rabbits 
by the organisms tend under certain conditions to produce the 
same type of bone change in the rabbit as that organism would 
in the patient. In another chapter (Chapter No. 22) we show 
that the organisms rapidly lose their elective localization quali- 
ties when transferred to another type of media. This makes it 
necessary that the organism shall be transferred with as much 
dispatch as possible from the patient to the animal, and with as 
little modification by artificial growth as is possible. 

Figure 29 shows the progressive history of a certain tooth : the 
upper right biscuspid. In 1901, twenty-two years ago, I made the 
roentgenogram shown as A, which was one of the early cases 
studied by this means. It shows clearly a tendency to a lessening 
of the density about the root apex. At this time I removed a poor 
and incomplete root filling; and after sterilizing the root with the 
regulation methods of the time, placed a new root filling with the 
assumption and confidence that all organisms had been destroyed 
and the tooth would remain in safe condition, for such w^as the 
confident teaching of the time. From time to time I made roent- 
genograms to determine that the bone was filling in about the 
apex. Six years ago I sent for the patient, having become con- 
vinced that it was not safe for her to have that tooth, notwith- 
standing the fact that it was apparently getting better, as proven 
according to the accepted fundamentals by the reconstruction of 
bone about the apex. In the meantime the patient had become 
progressively more seriously involved with rheumatic arthritis 
with so much rigidity that she had to be carried to the office. 
B of Figure 29 shows the dense bone forming about the apex. The 
tooth was not in the least tender. The tooth was extracted after 
using the actual cautery in the anesthetized gum at the neck of 
the tooth to destroy infection at the gingival border. It was cul- 
tured ; animals were inoculated. The culture of the tooth showed 
a very profuse streptococcal infection. Cultures were taken from 
the bone surrounding the root apex to a distance of one-fourth 
inch from the apex, which grew out the same type of organism 
notwithstanding its density. About four months later, the same 
bone was cultured by sterilizing the external alveolar tissue with 
a cautery, after anesthetizing, and going through into the alveo- 



76 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




Figure 31. A and B show two views of an extracted 

MOLAR ROOT OF THE CASE SHOWN IN FIGURE 30. WITH MARKED 
EXCEMENTOSIS FUSING THE MESIAL AND BUCCAL ROOTS, AND 
AT D, THE FIRMLY ATTACHED PIECE OF ALVEOLAR BONE. 






— 



CHAP. Ill l(K U, CHANGES PRODUCED B\ DENTAL INFE< riONS 77 

lar bone, and the same organism was found. C of Figure 29 shows 
this alveolar bone two years later, at which time the dense bone was 
becoming less dense. Incidentally, the patient improved after 
the extraction of these and other similar teeth so that she was able 
to get about on crutches, whereas formerly she had to be carried. 
Note that, in this case even the large quantity of infection in a 
hall tilled root canal of long standing, produced only a radiolu- 
cency without the development of granuloma. A lesser quantity 
of infection produced no radiolucency but a radiopacity. We 
are, in this patient, apparently dealing with forces which resemble 
in their effect those expressed in Figure 25, A-2 and B-3, and quite 
unlike those in Figure 25, A-l, B-l, and A-3. 

A careful study of the various types of local reaction found 
resulting from dental infections was made as a part of this re- 
search by comparing different teeth in the same individual. This 
was done with a large number of individuals. Figure 30 is a typical 
illustration. Here it will be noted that the roentgenographic 
evidence of the condition would indicate a similar type of condi- 
tion in the bone surrounding the roots of the many involved 
teeth. None had extensive absorption, notwithstanding the fact 
that we have the quantity of irritant that would be available from 
a putrescent pulp, as seen in the upper left first biscuspid and in 
the unfilled roots of the mesial root of the upper left first molar, 
all upper incisors, the mesial root of the lower right second molar, 
and the upper right first and second molars. The condition in 
this mouth, as revealed at the time of operation, showed that 
there was a very unusually dense bone about the roots of all the 
infected teeth, as also a marked excementosis of the roots of the 
upper left first molar which is show r n in photograph in Figure 31. 
It will be noted that the mesiobuccal and distobuccal roots are 
fused together so completely as to be a continuous mass. When 
this root was extracted, the alveolar bone was so adherent that 
a piece of it came away with these roots, shown in Figure 31-B. 

In striking contrast to this last case, we find many patients 
with very extensive areas of absorption about similarly involved 
teeth. Such a one is shown in Figure 32. In this case it will be 
noted, the upper central with very little evidence of unfilled root 
space has a very extensive zone of absorption, as does also the 
upper left first biscuspid and lower right first biscuspid ; and this 
is the more important because the former was a young person and 
this patient is fifty-six years of age. The matter of the compari- 



78 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




Figure 32 shows extensive absorption of alveolar bone 
about involved teeth of this individual, in contrast with 

FIGURE 31. 



CHAP. Ill LOCAL CHANGES PRODUCED B^ DENTA1 INFECTIONS 79 

son of the health of these two individuals is one which we \\ ill take 
up in subsequent chapters, for it lias very direct and important 
bearing on the type of pathology. 

A study was made of the different members of the family in a 
large series of families to ascertain whether the same general con- 
ditions tend to prevail; that is. whether a dental infection tends 
to produce the same type of tissue reaction about the teeth in the 
different members of a given family. Figure 33 shows a typical 
illustration of this study. In it we have the roentgenograph^ 
record of the reactions to dental infections in three sisters and a 
brother of the patient reported in Figure 31. It will be noted by 
comparison, for example, of the two roentgenograms shown in 
each A, B, C, and D, that there is a very marked similarity in the 
type of tissue change, as was also demonstrated at the time of 
surgical removal of these teeth in the clinical condition found. 
Note particularly the mesial root of the lower molar in A and part 
of the distal root of the same, give the same evidence of incom- 
plete root filling, which condition also exists in the upper right 
second molar. B shows a similar condition of a lower and an 
upper molar; C does of a lower molar; and D of an upper molar 
and incisors. If quantity had been the all-determining factor, as 
expressed by the capacity of the space left in the unfilled root, 
these might all be expected to have large apical areas of rarefac- 
tion. In all the teeth of these various members of this family 
there was found not only the similar condensing osteitis but a 
very great tardiness in the healing process. The sockets tended to 
become infected and painful, requiring relatively long periods for 
the filling in of the alveolus. It should be noted that in addition 
to the similarity of these members of this family from the stand- 
point of the local structural reaction to dental infections, there 
was also a marked similarity in systemic involvements, all of 
which were breaking at from twenty to thirty years of age. This 
we have discussed in further detail in Chapter 59. 

Similarly, in Figure 34, we have the roentgenograms of the 
teeth of the brother and sister of another family showing an 
entirely different type of reaction to dental infection. In this 
case there are areas of very extensive rarefaction about all in- 
volved teeth. At the time of surgical removal of these teeth it 
was found that, whereas in the last case they were all exceedingly 
difficult to extract and all surrounded by very dense bone, in this 
family they not only have roentgenographic evidence of exten- 



80 DENTAL INFECTIONS, ORAL AND SYSTEMIC RESEARCHES— VOL. I 







Figure 33. A comparison of the type of reaction in different 

MEMBERS OF THE SAME FAMILY. NOTE THE ABSENCE OF APICAL 
REACTION. 



sive areas of absorption in all members of the family where dental 
infections exist, but at the time of surgical removal it was also 
found that there was a marked similarity in the structural con- 
ditions. The teeth were easily extracted; the bone was not dense 
about them ; and the sockets healed with great rapidity and with- 
out discomfort or secondary infection. Nature in these instances 
did not require any assistance. 

A study was then made to see in what different groups indi- 
viduals could be placed, with regard to the type of reaction de- 




r 9~^ 





Figure 34. A comparison of the type of reaction in different members of the same family. Note 

THE PRESENCE OF EXTENSIVE APICAL REACTION. 

81 



82 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




Figure 3d. Different types of reaction about adjoining teeth. 




A B 

Figure 36. An apparent improvement in dental condition following break 
in health. 




Figure 37. Roentgenographs appearance of condensing osteitis about in- 
fected TEETH. 



CHAP. Ill LOCAL CHANGES PRODUCED B1 DENTAL INFECTIONS 83 

veloping in tissue, as a result of various types of dental infections, 

and it was found that in addition to the two types illustrated 
above, there was frequently found a type which was similar in 
many respects to that in Figure 34, except that the area of rare- 
faction seemed bounded by a zone of more dense bone, as it were, 
a zone of condensing osteitis around one of rarefying osteitis. 
This type is illustrated in Figure 37. It was found that the vari- 
ous patients having this type of condition were comparable in 
that the teeth were frequently difficult to extract, often had a 
history of a fistula having existed previously, and closing sockets 
did not heal as readily as the type in Figure 34. In many respects 
individuals of this class presented sockets that were similar to 
those in Figure 33 in the condition found clinically and the difficul- 
ties attending the healing process, while the conditions roent- 
genographically resembled in a general way in that there were 
frequently large areas of absorption, the type of reaction found 
in the group as shown in Figure 34. 

While extensive rarefaction as a result of infection, and con- 
densation or absence of rarefaction, may be typical expressions 
of different types of systemic reaction, therefore appearing in 
different individuals with different physical characteristics, it is 
possible to find both these conditions in the same individual, as 
shown in Figure 35 which shows a very marked area of alveolar 
absorption around the root of the first biscuspid with no absorp- 
tion around the second biscuspid, which latter has an excemen- 
tosis. This will appear to some like a contradiction. It probably 
is due to the following conditions: It will be noted that the first 
biscuspid with its large area of absorption has a zone of condensed 
bone surrounding that zone of rarefaction ; also that it has evidence 
of an absorption process on the root; and this tooth had all the 
infection of the unfilled pulp canal in addition to the infected 
dentin as a source of irritation. The second bicuspid has a root 
filling and probably has very much less total infection and capac- 
ity' for toxic material than the first bicuspid. It is also probable 
that in addition to this great difference in quantity, the condens- 
ing osteitis of the first bicuspid has formed during a period sue - 
ceeding the period during which the absorption developed; and 
it will be shown later that the condition of excementosis about 
the second bicuspid has probably taken place during the period 
in which the condensing osteitis surrounding the rarefying osteitis 



84 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




Figure 38. A group showing extensive rarefying osteitis about infected teeth. 



CHAP in LOC U, CHANGES PRODI ( ED B\ DEN1 \l INFE( I IONS 85 

occurred about the first bicuspid. Just as in geology the recorded 
depositions may represent entirely different conditions because 
they occur in different periods, similarly, recorded bone changes 
may chronicle entirely different types of fraction because they 
belong to different periods; in other words, one of the important 
elements involved is the environment, together with the fact that 
a small quantity of irritation may be sufficient to produce just 
enough stimulation to make a deposition; whereas, a much larger 
quantity goes beyond the point of stimulation to irritation and 
produces rarefaction. 

If, as we have suggested, individuals may change their capacity 
for reaction to a given dental infection, we should find evidence 
of this about teeth which have not been subjected to surgical in- 
terference or medication. Such a condition is shown in Figure 36 
in which in A we have the extent of the zone of rarefaction about 
an infected bicuspid root and which six months later, as shown in 
B, has a smaller area. It is not probable that the infection has 
become less serious either in virulence or quantity. There is an 
important relationship, however, to the patient's health which 
will come out in the next chapter. 

We have, accordingly, studied carefully a very large number of 
roentgenograms covering all of those in a busy clinical practice 
for many years, and have found evidence in the roentgenograms 
to suggest their classification into three main groups on the basis 
of the type of structural change produced in the supporting 
structures about infected teeth. We have, accordingly, made up 
a page of each of these three groups: namely, those in which 
there is evidence in the roentgenogram of a vigorous reaction 
about the tooth, expressing itself with extensive absorption of 
alveolar bone and in some instances with absorption of the roots 
themselves. We have placed the centrals and laterals at the top, 
bicuspids next, and molars at the bottom. Figure 38 shows the 
group with this splendid reaction. 

In the next group I Figure 39) we have presented those in which 
there is evidence of a change in the type of reaction in which there 
has been originally a very abundant absorption, but about the 
periphery of which absorption area there is evidence of a con- 
densed layer in contrast with the preceding group in which in 
many or most instances the zone diffuses off into cancellous bone. 
Whereas the medullary spaces are frequently enlarged and have 
direct connection with the absorption chamber, in this group there 



86 DENTAL INF ECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




Figure 39. A group showing a zone of condensing osteitis surrounding a zone of 

RAREFYING OSTEITIS ABOUT INFECTED TEETH. 



CHAP. Ill LOCAL CH tNGES PR( >DUCED BY DENTA] INFECTIONS 

is a reduction m the medullary spaces with an enlargement of 

the trabeculae adjoining the absorption chamber, which latter 
is frequently surrounded by a dense continuous bony shell, often 
polished like the inside of an egg shell, with occasional or very 
few connections with the medullary spaces. There is evidence 
of distinct change in the progress of this reaction; whereas 
there was one time an active absorption with enlargement of 
the chamber, there is now a deposition at the periphery of the 
granulomatous tissue with the obliteration of the medullary spaces. 

A third group is shown in Figure 40, in which there has never 
been an extensive zone of absorption about the root apices and in 
many instances there seems to have been much obliteration of the 
cancellous structure of the bone. The medullary spaces are small 
or lost by the fusing of the trabeculae. In this group there is no 
evidence of there ever having been a fistula. The teeth were 
seldom, if ever, tender. There is very little reaction about the 
tooth and what there is, is largely a deposition process about a 
very small zone of rarefaction. 

Clinically, there are many characteristics in common in the 
members of these groups but in contrast with those of the other 
groups. For example, in the teeth of the first group there is 
generally a fistula with recurring exacerbations of tenderness or 
painfulness. This is continued to the present. The sockets left 
after the extraction of the teeth of the first group tend to heal 
readily without treatment or tendency to local infection. The 
members of the second group often show the evidence of an old 
scar of a fistula but none, of late. Formerly the tooth got tender 
but not so, recently. These teeth tend more to infection of the 
sockets following extractions than those in Group 1 and require 
more postoperative care after exodontia. Those in Group 3 
never had a fistula; seldom, if ever, became tender; the sockets 
tend very readily to infection after exodontia, often very painful 
requiring careful postoperative care, for both this group and the 
one preceding tend readily to develop what is frequently referred 
to as dry socket following extraction, which the former group in 
Figure 38 never does. Another characteristic of the groups will 
be that the teeth in Group 1, Figure 38, tend to be extracted easily, 
those in Group 2, Figure 39, quite difficult, and those in Group 3, 
Figure 40, often exceedingly difficult. With regard to infiltrative 
anesthesia, those in Group 1 are very readily anesthetized ; those 
in Group 2 less so; and those in Group 3 tend to be very difficult. 



DENTAL INFECTIONS, ORAL AND SYSTEMIC—RESEARCHES— VOL. I 




Figure 40. A group showing limited reaction, with or without condensing osteitis 

ABOUT INFECTED TEETH. 



CHAP. Ill LOC \l CHANGES PRODUCED B^ DENTAL INFE( riONS 89 
SUMMARY AND CONC1 I SIONS. 

1. An analysis of these data reveals that the fust premise 
namely, that infection will express itself in l><»i< as absorption is 
not a constant finding, assuming that the quantity of infection 
that would bo represented by an infected pulp of a single rooted 
tooth represents approximately the same quantity for a given 
tooth in various individuals. The extent of absorption is not the 
same in all these individuals, for there may be very extensive 
absorption in one ease and in the very next case very little ab- 
sorption or a previous deposition of bone, or both. And this 
difference is not explainable on the basis of quantity; for, indeed, 
it will often be found that whereas in some cases the local effect of 
the quantity of infection represented in large pulps which are 
putrescent, therefore large quantities of infection, may be exceed- 
ingly small; and in other cases with even very small pulps or 
nearly filled pulp chambers, or even completely root-filled canals, 
there will be enough irritation to produce very large areas of 
absorption. 

2. \\ ith regard to the matter of grouping of individuals, it is 
very evident that members of the same family tend to have the 
same type of reaction about their teeth, immediately suggesting 
an evidence of grouping. 

3. Frequently in the study of individuals we find cases with 
quite extensive absorption but which areas are surrounded with 
zones of apparently dense bone. These individuals seem clearly 
to have had a change come into their lives. They have at one 
time been in the first group and have finally come to be in the 
second group. As a class these individuals are so characteristic 
that they can readily be put into a group by themselves on the 
basis of the local structural change about their teeth; for the in- 
oculation of experimental animals with cultures taken from den- 
tal sources has revealed variations in conditions which vary 
through a wide range, from very marked absorption of bone to 
very definite deposition within the bone. 

We can therefore briefly summarize as follows : 
(a) Dental infection in bone may express itself as ab- 
sorption, even extensive absorption, or may be at- 
tended by very little or no absorption, or may even 
produce a marked increase in the density of the 
bone, (b) A given dental infection will not express 
itself in the local tissues of the mouth approxi- 
mately the same in all people. People tend to divide 
into groups with regard to this matter of local 
reaction, which groups are very dissimilar. 



CHAPTER IV. 

SYSTEMIC STRUCTURAL AND FUNCTIONAL CHANGES 
PRODUCED BY DENTAL INFECTIONS. 

PROBLEM: Are all human beings similar or sufficiently 
so that they may be considered comparable in their reactions 
to dental infections? 

INTRODUCTION. 

If, as seems indicated from the preceding researches, the pres- 
ence or absence of systemic involvements and their nature is not 
dependent primarily upon biological characteristics of the organ- 
isms involved, and if the local structural changes about the teeth 
are not the same in different individuals for a given or similar type 
of infection, there is strong evidence that other factors must be 
responsible for the presence or absence of local and systemic 
effects from dental infections. Historically, about all that has 
appeared in the literature has been a reference to a rheumatic 
diathesis influenced by racial, climatic, geographic, industrial, 
and environmental conditions. 

EXPERIMENTAL AND DISCUSSION. 

A fundamental law of biology, physics, and chemistry, is that 
similar causes produce similar effects; and since this is a bio- 
logical problem, it has been very natural to suppose that even 
though the factor involved in the invading organism is variable, 
the factor involved in the host is a common and universal one. 
In fact, a department of applied medicine is based on this assump- 
tion : namely, clinical pathology or diagnosis. Not that all people 
exposed to typhoid develop a typical case of typhoid fever, but 
that those who do become a prey to this infection develop similar 
symptoms; and upon this symptomatology the disease is identi- 
fied. This presupposes (1) that the invading typhoid or- 
ganisms will, in general, have the same powers of attack varying 
within certain limits in severity, selecting the same tissues, and 
(2) that the reactions in the patient will be clinically similar. 
This being true of a great majority of pathogenic organisms has 

90 



CHAP. l\ \Kl HUMAN BEINGS COMPARABU '.'I 

made it possible lor a very genera] and quite effective classifica- 
tion of infectious diseases to be made, whether ihe infection 

entered the system by the respiratory tract, the digestive tract, 
or by implantation within the tissues. The invasion of the or- 
ganisms has resulted in local and general tissue reactions which 
have been termed symptoms, and on this the whole department 
of clinical medicine or clinical diagnosis has been based. The 
near universality of this rule of symptomatology has made it very 
natural and logical that the same general fundamental principles 
would be understood to apply to both the aggressive qualities of 
the organisms in dental infections and the reactions of the host 
to such an infection if it existed. 

Applying this general law of clinical medicine, we have con- 
cluded that people who are well, or are not ill, are not infected; 
and, similarly, teeth that are well, or at least not ill, are not in- 
fected ; and teeth that have been ill and have become apparently 
well have ceased to be infected. The answer to the questions 
"What constitutes a sick or afflicted tooth?" and "What are the 
symptoms of an infected tooth?" has been determined by the 
same law of symptomatology. Since, with practically all infec- 
tions the severity of the symptom is an expression of the severity 
of the involvement, therefore we have argued that teeth with 
serious inflammatory processes, whether in the pulp which is so 
capable of expressing abnormal states or in the peridental mem- 
brane, a tissue nearly as responsive, are or are not seriously in- 
fected in proportion to the pain and evidences of inflammation 
involved. This has implied that the attacking power of the 
invading organisms, the reacting pow-er of the host, and the result- 
ant of the reaction — namely, the clinical symptoms — will be com- 
parable in various individuals as well as in various teeth of the 
same individual. 

To determine this we have made a very careful analysis of 
fourteen hundred cases in order that we might ascertain the correct- 
ness of this presumption. We have undertaken to establish, so 
far as was feasible, the following factors: The characteristics of 
the host, including susceptibility to caries and susceptibility to 
gingival infections or periodontoclasia; the characteristics of the 
local histopathology ; the tendency to systemic involvements and 
their kind ; whether there is a definite susceptibility to the type of 
organism usually found in dental infections; whether that factor 
has developed recently, or whether it has been the characteristic 



92 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

throughout life; whether it is an inherited characteristic, whether 
its dominance is marked, and whether inherited from both sides 
of the ancestry; and the effects of overloads and the nature of 
those most involved. 

We have found it very difficult to establish what might be con- 
sidered a normal individual; and, in any group, to know how 
divergent they of that group are from the normal ; or, of the indi- 
viduals studied, what percentage any group might form of the 
total of society. We have undertaken to establish what might be 
considered normal individuals by selecting from those examined 
those most free from systemic involvements. We have accord- 
ingly found a very constant grouping of individuals which we 
shall later analyze in detail. The Chart in Figure No. 41 shows the 
general result of this study. 

INTERPRETATION OF RESULTS OF SUSCEPTIBILITY 
EXPERIMENTATION 

Many very interesting and unexpected units of information 
have been revealed, which seem to establish very definitely that 
human beings are not similar in the sense that the same rules can 
be applied to all and various individuals for the interpretation 
of the immediate symptoms or of their significance. In general 
we find that all individuals divide naturally into two main groups 
so far as the presence or the probable presence of systemic re- 
actions to dental infections is concerned. We have chosen to call 
these groups non-susceptibles and susceptibles. The latter group, 
the susceptibles, naturally subdivides into two. The first is a 
group whose susceptibility is an acquired factor. It is made up of 
people who belong in the non-susceptible group, but who, because 
of various forms of overload which will be discussed later, have 
come into the group we have termed acquired susceptibles. There 
are many things which distinguish this sub-group from the bal- 
ance of the general groups we have called susceptibles. The 
second division of the susceptibles has characteristics which are so 
outstanding that they make themselves readily recognized. They 
have never been in the first group, or non-susceptibles, and while 
they may not have broken during long periods of their life, they 
have tended to break with the presence in the system of the type 
of infection requisite for making manifest that inherited suscep- 
tibility. This type of infection, as will be seen, is found in prac- 
tically all dental lesions. There seems to be truly an inherited 
quality which, as is disclosed, shows very definitely evidences of 



CHAP. IV— ARE HUMAN BEINGS COMPARABLE? 



93 















RHEUMATIC GROUP LESIONS OF INDIVIDUALS AND THEIR RELATIVES 






















Susceptibility Studies by Alphabetical Groups 






















I 
Z 

0) 

■a 
1 










Number of Relatives 




Number of Lesions in Individuals 






] 


dumber of Lesions Severe and Severe and Mild in the 




1 

■a 
1 

30 


J 
11 

£z 


01 

bo 
< 
CD 

bo 

i 

> 
< 


3 
Z 

CD 

i 


oj 

bO 
< 
01 

bo 

s 

1 


01 
M 

< 

u 

bO 

9 

i 
> 

< 




of Individuals 




Affected 




and their Families 








Three Susceptibility Groups 






CO 

i 

c 
o 
H 

13 


CO 

r 

13 


4-* 
\ 

X 
5 


z 

12 


<0 
g 

z 

16 


2 c 

5 Ef 
,5° 

12 


14 


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o 

b3 

13 


CO 

CD 
CO 

i/3 
13 


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15 


CO 

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V i 

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9 


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S 
16 


-"8 

11 


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28 


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Inherited 


ja a. 
Z.S 


Acquired 


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(22 

z.s 


Absent 


CD 

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> 

CD 


CD 
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CD -0 

60 CD .2 
U. CD *> 


CD 
C 

CD 
> 
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in 


CD 

bO CD 
S S 
CD > 
> CD 


CD 

«3-o2 

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Average 
Severe 
and Mild 


CD 

V 

> 

5 


CD 

bo CD 

n 


CD 

«^- 
CD S 5 

on ^ 




A 


18 


41.6 


5 


44.6 


13 


40.4 


35 


131 


50 


37 


278 


15.4 


369 


20.5 


220 


20.0 


286 


26.0 


6 


53 


8.8 


77 


12.8 


1 


5.0 


6 


6.0 


B 


28 


42.0 


6 


37.1 


22 


43 3 


16 


17 


10 


17 


25 


18 


23 


12 


20 


24 


14 


21 


14 


37 


69 


39 


29 


164 


96 


bV 


310 


11.1 


491 


17.5 


14 


219 


15.6 


301 


21.5 


8 


60 


7.5 


113 


14.1 


6 


31 


5.2 


77 


12.8 


C 


41 


42.0 


15 


41.7 


26 


42.2 


22 


22 


12 


21 


29 


23 


24 


19 


23 


30 


16 


25 


21 


47 


98 


48 


3b 


163 


139 


bb 


417 


10.2 


596 


14.5 


20 


307 


15.3 


431 


21.5 


10 


62 


6.2 


85 


8.5 


11 


48 


4.4 


80 


7.3 


D 


3 


36.0 







3 


36.0 


1 


3 


2 


3 


3 


2 


3 


2 


2 


2 


1 


3 


3 


8 


20 


14 


9 


29 


10 


24 


53 


17.6 


114 


38.0 


3 


53 


17.7 


114 


38.0 






















B2 


4fi 


43.9 


14 


47.6 


32 


42.3 


16 


29 


12 


28 


39 


33 


26 


23 


27 


34 


17 


32 


22 


29 


93 


50 


38 


239 


lbV 


b8 


49b 


10.8 


664 


14.4 


25 


365 


14.6 


473 


18.9 


15 


113 


7.5 


160 


10.7 


6 


17 


2.8 


31 


5.2 


D 


27 


43.0 


8 


47.6 


19 


41.0 


13 


18 


6 


18 


22 


13 


19 


16 


10 


22 


9 


21 


9 


27 


76 


34 


33 


156 


71 


70 


302 


11.2 


467 


17.3 


13 


201 


15.5 


326 


25.1 


8 


50 


6.2 


77 


9.6 


fi 


51 


8.5 


64 


10.7 


E 


11 


42.6 


3 


38.7 


R 


44.1 


8 


7 


2 


6 


11 


10 


7 


7 


8 


7 


4 


5 


7 


9 


24 


8 


9 


42 


38 


16 


10b 


9.6 


146 


13.3 


5 


67 


13.4 


86 


17.2 


4 


30 


7.5 


45 


11.2 


2 


9 


4.5 


15 


7.5 


F 


11 


43 


7 


39.6 


4 


49.0 


8 


5 


4 


7 


9 


8 


9 


8 


5 


9 


5 


8 


6 


18 


30 


18 


12 


33 


42 


27 


97 


8.8 


180 


16.4 


4 


48 


12.0 


83 


20.7 


3 


26 


8.7 


50 


16.7 


4 


23 


5.7 


47 


11.7 


FG 


59 


43.4 


18 


48.3 


41 


41.2 


28 


33 


17 


38 


48 


31 


43 


25 


22 


35 


16 


47 


28 


56 


108 


73 


51 


281 


137 


111 


543 


9.2 


817 


13.8 


32 


388 


12.1 


583 


18.2 


19 


130 


6.8 


198 


10.4 


8 


25 


3.1 


36 


4.5 


H 


44 


44.0 


fi 


51.5 


38 


42.8 


19 


32 


R 


28 


33 


26 


26 


20 


21 


33 


14 


37 


24 


37 


110 


49 


45 


208 


148 


69 


486 


11.0 


666 


15.1 


30 


401 


13.4 


533 


17.8 


7 


57 


8.1 


81 


11.6 


7 


28 


4.0 


52 


7.4 


I 


4 


43.2 







4 


43.2 


3 


3 


2 


2 


3 


3 


3 


3 


2 


3 


1 


3 


1 


3 


19 


7 


3 


46 


21 


13 


85 


21.2 


112 


28.0 


3 


84 


28.0 


111 


37.0 












1 


1 


1.0 


1 


1.0 


J 


17 


37.4 


4 


39.0 


13 


36.8 


7 


8 


4 


12 


14 


8 


14 


9 


8 


12 


4 


11 


5 


15 


28 


16 


14 


62 


37 


22 


128 


7.5 


194 


11.4 


8 


91 


11.4 


125 


15.6 


6 


31 


5.2 


51 


8.5 


3 


6 


2.0 


18 


6.0 


K 


33 


37.2 


10 


36.2 


23 


37.7 


21 


20 


3 


18 


29 


20 


22 


19 


21 


27 


14 


27 


16 


58 


120 


42 


57 


294 


158 


lib 


616 


18.7 


844 


25.6 


17 


505 


29.7 


663 


39.0 


10 


89 


8.9 


142 


14.2 


6 


22 


3.7 


39 


6.5 


L 


29 


38.0 


8 


39.6 


21 


37.4 


16 


18 


9 


21 


26 


20 


22 


15 


19 


21 


15 


23 


19 


31 


72 


36 


38 


194 


86 


64 


360 


12.4 


521 


17.9 


21 


311 


14.8 


441 


21.0 


4 


27 


6.7 


48 


12.0 


4 


22 


5.5 


32 


8.0 


Ml 


12 


44.2 


3 


37.7 


9 


46.3 


4 


8 


2 


8 


11 


10 


11 


7 


7 


11 


2 


10 


7 


9 


32 


9 


14 


73 


41 


20 


155 


12.9 


198 


16.5 


8 


120 


15.0 


151 


18.9 


2 


26 


13.0 


31 


15.5 


2 


9 


4.5 


16 


8.0 


M2 


56 


37.4 


12 


36.1 


44 


37.7 


34 


36 


13 


29 


45 


31 


41 


27 


29 


41 


22 


48 


33 


71 


152 


79 


46 


320 


179 


114 


657 


11.7 


961 


17.2 


39 


568 


14.6 


804 


20.6 


14 


77 


5.5 


140 


10.0 


3 


12 


4.0 


17 


5.7 


P 


35 


42.2 


11 


49 


24 


39.1 


13 


23 


6 


18 


24 


22 


19 


12 


12 


22 


12 


27 


19 


35 


71 


47 


29 


147 


97 


6b 


300 


8.6 


491 


14.0 


17 


215 


12.6 


358 


21.1 


11 


51 


4.6 


85 


7.7 


7 


34 


4.9 


48 


6.9 


NO 


18 


35.3 


5 


39.4 


13 


33.7 


9 


13 


10 


11 


14 


8 


12 


9 


9 


15 


8 


14 


10 


29 


71 


43 


34 


128 


78 


54 


317 


17.6 


437 


24.3 


14 


301 


21.5 


412 


29.4 


3 


13 


4.3 


20 


6.7 


1 


3 


3.0 


5 


5.0 


R 


17 


44.9 


7 


46.6 


10 


43.7 


7 


11 


2 


7 


12 


7 


10 


10 


6 


12 


4 


12 


8 


12 


35 


10 


9 


68 


46 


20 


147 


8.6 


200 


11.8 


9 


90 


10.0 


122 


13.6 


7 


57 


8.1 


78 


11.1 


1 





0.0 





0.0 


SI 


36 


43.2 


13 


47.4 


23 


40.9 


23 


23 


6 


21 


30 


24 


21 


14 


14 


26 


18 


26 


15 


32 


72 


47 


31 


160 


121 


39 


370 


10.3 


502 


13.9 


24 


300 


12.5 


404 


16.8 


4 


31 


7.7 


47 


11.7 


8 


39 


4.9 


51 


6.4 


S2 


20 


41.4 


8 


44.2 


12 


39.5 


8 


13 


6 


11 


16 


10 


12 


10 


11 


16 


6 


15 


8 


16 


42 


26 


16 


89 


50 


35 


183 


9.1 


274 


13.7 


13 


148 


11.4 


207 


15.9 


5 


30 


6.0 


54 


10.8 


2 


5 


2.5 


13 


6.5 


T 


25 


44.1 


8 


40.6 


17 


45.7 


16 


18 


8 


20 


24 


17 


21 


15 


10 


17 


12 


21 


14 


28 


62 


45 


27 


155 


70 


41 


320 


12.8 


428 


17.1 


19 


282 


14.8 


374 


19.7 


3 


26 


8.7 


37 


12.3 


3 


12 


4.0 


17 


5.7 


V 


9 


44.4 


5 


39.2 


4 


51.0 


2 


3 


2 


6 


8 


5 


8 


6 


4 


3 


3 


8 


2 


2 


15 


3 


9 


48 


13 


16 


70 


7.7 


106 


11.7 


4 


41 


10.2 


63 


15.7 


5 


29 


5.8 


43 


8.6 












w 


55 


39.7 


15 


40.5 


40 


39.4 


35 


35 


15 


34 


43 


29 


38 


30 


29 


41 


24 


46 


29 


65 


131 


96 


51 


289 


164 


102 


628 


11.4 


898 


16.3 


34 


524 


lb. 4 


730 


21.5 


12 


80 


6.7 


117 


9.7 


9 


24 


2.7 


51 


5.6 


YZ 


9 


34.5 


2 


31 


7 


35.6 


7 


5 


5 


6 


7 


5 


6 


6 


3 


5 


4 


8 


3 


12 


21 


13 


7 


41 


24 


20 


91 


10.1 


138 


15.3 


6 


78 


13.0 


108 


18.0 


3 


13 


4.3 


30 


10.0 












S3 
Totals 


18 


41.7 


6 


43.2 


12 


40.9 


11 
360 


12 
428 


5 
176 


14 
416 


14 

555 


11 
406 


14 

468 


9 

346 


13 
348 


15 
498 


9 
263 


15 
529 


12 

346 


24 


54 


29 


21 


99 


53 


43 


208 


11.6 


323 


17.9 


12 


168 


14.0 


261 


21.7 


5 


36 


7.2 


54 


10.8 


1 


4 


4.0 


8 


8.0 


681 


1070.3 


199 


1006.4 


482 


1070.9 


738 


1690 


916 


690 


3659 


2126 


1318 


7722 


307.1 


11137 


4b3.4 


405 


6095 


398. b 


8550 


570.4 


174 


1197 


170.0 


1863 


265.2 


102 


430 


89.9 


724 


152.4 


(Note 




41 2 


29% 


41.9 


71% 
lldat 


41.2 
ion 












































11.8 




17.4 
































: Thlscha 


rt Is a conso 


Average Number of Breaks 
per 100 Individuals in 


Percentage of Relatives 
Affected 


Average Number of Breaks 
per Family in 


Average Number of Lesions Severe, and Severe and Mild, per Susceptibility Group 


59 


Susceptibility Inherited 


26 


Susceptibility Acquired 


15 


Susceptibility Absent 


53 

m 

I 


63 

§ 
n 

E 
3 
u 

E 


26 

S 
a 


61 



Z 


81 

b 
Z 


60 

CO 

C 
C 


70 

Q 

3 

"ra $ 
a 


51 

w 
CD 

g 


51 

CO 

u 


73 

1 


39 

> 

fc-.2 

tu"o3 

■5K 

ra 


78 

u 
£ 

o 

2 


51 
-"1 

!* 
2 


1.08 
1 

1 


2.48 

S 

■3 

cd 

u 

.c 

s 


1.35 

i 

<U 


1.01 

u 

u 

Z 


5.37 

01 

z 


3.12 


1.94 


11.34 


11.34 


16.35 


16.35 


15.05 


15.3 


21.11 


21.9 


6.88 


7.1 


10.71 


11.0 


4.22 


4.1 


7.098 6.9 


to 

■a § 

cuO 

c 


8 

3 
"3 CO 

a 

t/5 


CD 

> 

< 


Bfil 

2f u2 


CD 

ftf CD 
CD C/) 
> 

< 


Average 

Severe 

and Mild 


CD 

Si 

> 
< 


Average 

Severe 

and Mild 


CD 
Sf > 

> 
< 


Average 

Severe 

and Mild 




















SUMMARY 






of 14 


0,000 deter 


ruinations 


sonic 


; of 




The summary at th 


e right (bold face) is an analysis of the susceptibilities of the patients 






Susceptibility Inherited 


Susceptibility Acquired 


Susceptibility Absent 


whlcl 


i took m 


inutes, an 


d si 


me 






and their families to the rheumat 


ic group lesions 




Average Severe 


15.05 


Average Severe 6.88 


Average 


Severe 4.22 


hour 


9 of time.) 


















Average Severe & Mild 


21.11 


Average Severe & Mild 10.71 


Average Severe & Mild 7.089 



Figure 41. 



CHAP. H VRE HUMAN BEINGS COMPARABU 95 

the laws of mendelism. Accordingly, we have divided all individ- 
uals into three main groups: the first, those with non-suscepti- 
bility; the second, those with an acquired susceptibility; and tin- 
third, those with an inherited susceptibility. An illustration 
familiar to everyone from earliest recollection will be the common 
phrase "Heart disease runs in this or that family." 

A detailed description of what is presented in the chart in 
Figure 4 1 is as follows : The letters of the alphabet, called "Alpha- 
betical Group," represent the first letter of the patient's name in 
order that a comparison may be made of as many different groups 
as there are letters of the alphabet for the purpose of showing the 
const ancy of percentages, etc. The succeeding columns are 
"Total Number per Alphabetical Group, Average Age, Number 
of Males, Their Average Age, Number of Females, Their Average 
Age." The next section of the chart is entitled "Number of 
Rheumatic Group Lesions (past and present) of the Individual 
Being Studied" under which we have Tonsils, Rheumatism, 
Heart, Neck, Nerves, Internal Organs, and Special Tissues. The 
next division entitled "Number of Relatives Affected" indicates 
the number of instances in the group where Brothers, Sisters, 
Father, Father's Relatives, Mother, Mother's Relatives were 
affected with rheumatic group lesions. The next column is a 
combination to show the number of Severe, and Severe and Mild 
instances of rheumatic group lesions of the patient and family. 
These include the subdivisions of Tonsils, Rheumatism, Heart, 
Neck, Nerves, Internal Organs, Special Tissues, Total Severe 
Lesions (by which we mean those severe enough to incapacitate 
them or put them to bed or cause death), Percentage Severe, 
Total Severe and Mild Lesions, and Percentage of Severe and Mild. 

The balance of the chart, which is divided into three main 
groups, consists of a study of the number of lesions severe, 
and severe and mild, in the three susceptibility groups, 
iiiherited, acquired, and absent. In all of these three groups we 
have in the first column the number of patients in the group, 
followed by the severe lesions, the average severe lesions, the 
severe and mild lesions, the average severe and mild lesions. It 
will be noted that if the figures showing percentage in any of the 
three groups, as, for example, Average Severe or Average Severe 
and Mild, are read downward, they show a marked similarity in 
those collections of patients which would be represented by the 
first letters of their names. 



96 DENTAL INFECTIONS. ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

The figures at the bottom of the chart show the average num- 
ber or percentages as per the various groupings as expressed. 
The heavy black leaded summary at the bottom gives the con- 
densed summary of this very extensive study. The data here 
revealed constitute what I believe to be one of the most funda- 
mental and far-reaching, but generally overlooked, forces operat- 
ing to determine the nature of the systemic expressions of dental 
infections. 

In a group of non-susceptibles consisting of 102 persons, which 
included all of those who did not have rheumatic group expres- 
sions (degenerative diseases) and never had had, either from 
dental or other origin, which were found in 681 cases selected 
from about 1400 because the records of their cases were consid- 
ered sufficiently detailed and exact for scientific and comparable 
study, we find that this factor of immunity of the persons of this 
group consisting of 102 individuals, pertains in general also to all 
the other known members of those family circles; by which, we 
mean the immediate individuals in three generations: namely, 
the brothers and sisters of the individual, his or her father and 
mother and their brothers and sisters, and the grandparents of 
the individual. 

We have termed the group of lesions produced by streptococcal 
infection the Rheumatic Group lesions, and have selected for our 
classification only such as were severe enough seriously to distress 
or incapacitate the patient. When we compare first the individ- 
uals in these three groups of absent susceptibility, acquired sus- 
ceptibility, and inherited susceptibility, we find a very remarkable 
difference in their tendency to affections of the rheumatic group 
lesions. But even more striking and significant it is to find that 
this same quality tends to run as a constant law through the other 
members of their families; for, whereas the average number of 
severe rheumatic group lesions in the individual and the entire 
family as outlined is in the absent group only 4.2, in the acquired 
group it only increases to 6.8, but in the inherited group jumps to 
the remarkable figure of 15.05. And even more striking is 
the comparison of the average incidence of the severe and 
mild rheumatic group lesions which in the absent group is 7, 
acquired susceptibility group 10.7, and in the inherited suscepti- 
bility group jumps to 21.1. 

I repeat this is one of the most important new truths that has 
been presented on this whole problem of the relationship existing 



CHAP. I\ \KE HUMAN BEINGS COMPARABU 97 

between local infections and the deficiency and degenerative 
diseases. Its significance cannot possibly be appreciated by sim- 
ply reading it; for when the diagnostician thoroughly visualizes 
this great new truth, he will find himself playing the game of diag- 
nosis with marked cards. He can pretty nearly make out either 
the patient's chart from the family record or vice versa. Imme- 
diately it will be realized that if the factor of danger is entirely 
different in these different groups, the factor of responsibility 
increases with that danger, and also that the individuals in the 
latter group must have an entirely different set of standards as 
to what shall be condemned or retained, from those with the much 
larger factor of safety. This will be developed in detail in the 
succeeding chapters. 

The reader should have in mind in studying these results that 
the patients coming to a dental clinic such as this, include a much 
larger percentage of individuals with definite involvements than 
those found in an ordinary practice, since we have been specializ- 
ing in dental diagnosis, dental pathology, and dental research. 
The percentages cannot, therefore, be considered as directly ap- 
plicable to either the groups that would be made up in some other 
practice, or with the average people on the street. 

We desire at this point to explain in a general way the method 
of making these examinations, and the detailed analysis of the 
method of diagnosis will be found in Chapter 59. On the pre- 
sumption that there is more or less danger of exposure to rheu- 
matic group lesions for every individual, differences in the preva- 
lence of a break might furnish information that would help to 
point to the characteristics of individuals which have or have not 
a high defense, and by studying large groups we would be more 
likely to select those fundamental qualities which are characteris- 
tic and causative, or at least contributing factors. We have as- 
sumed that many individuals know whether or not they have had 
acute pain in their joints which has put them to bed, or have had 
a sense of being short of breath and exhausted from going up- 
stairs, which their physician has told them was due to a condition 
of their heart, etc.; and that they could be depended upon in a 
general way to have information that would be of value for com- 
parison, if not always exact. I can anticipate with relative cer- 
tainty, based on past experience, that it will be argued that an 
individual will not know whether the parents and their brothers 
and sisters died of heart trouble or Bright's disease, or had rheu- 



98 DENTAL INFECTIONS. ORAL AND SYSTEMIC -RESEARCHES— VOL. I 













COMPARISONS 


OF 


St| 






No. 


Patients' 


Lesions 


in % 


























100 


















r. 


Susceptibility 














£ 3 








> 


■: 


Class 










E 

to 




be <£ 








id 


c 




Age 


M 


F 






O H 








3 

OS 













CO 

'7r> 

C 

o 
H 


Rheumal 
Heart 


Neck 
Nerves 


Internal 
Special 


3 

■*-> 
O 

m 


CD 
35 


en 
S3 

• 


"en 
»- 
83 

A 


°> 1 

8 


Averages of Total No. 


41.3 


29 


71 


53 


63 26 


61 81 


60 70 


51 


51 


73 


39 


78 E 


Groups of 15 


























Absent 


40.7 


53 


47 


27 


13 


13 13 


7 7 








27 


7 


33 2 


Acquired 


47.9 


40 


60 


40 


47 20 


53 87 


53 53 


27 


7 


13 





13 


Inherited 


43.4 


33 


67 


53 


93 13 


60 80 


47 47 


33 


47 


60 


40 


67 6 


1 side mild 


























Inherited 


40.9 


20 


80 


60 


87 40 


73 80 


67 73 


60 


73 


80 


47 


93 7 


2 sides mild 


























Inherited 


39.4 


27 


73 


47 


93 27 


80 100 


67 87 


33 


40 


67 


40 


80 e 


1 side strong 


























Inherited 


33 9 


7 


93 


80 


73 80 


93 100 


93 87 


80 


73 


100 


100 


100 ?. 


2 sides strong 



























Figure 42. 

matism or neuritis; to which I will reply that we have excluded 
nearly half of the records taken because the patients did not know 
sufficient detail regarding these facts; and also, that if the cause 
of the parent's death was sufficiently impressed upon the minds of 
the patients that they could say clearly that it was from Bright's 
disease or heart, etc., they were generally correct, which we have 
determined by making a large number of verifications by com- 
munications with family physicians. I would also emphasize 
that since if the patient did not feel sure no entry was made, the 
effect on the record would be that the individual in question was 
clear and the total effect would be to make the case less strong 
than it should be rather than more strong than it should be. If 
then our percentages seem high with incomplete records, we are 
very sure that they would be much higher if we had complete 
records in all cases. That this is true, we have demonstrated to 
our satisfaction by establishing groups where we were able to get 
very complete records for all or most of the individuals involved, 
and in those cases, as will be shown presently, the percentages 
are very much higher. 

We selected fifteen families in each of the following groups: 
non-susceptibility or absent, acquired susceptibility, inherited 
susceptibility one side mild, inherited susceptibility both sides 



i HAP l\ VRE HUMAN BEINGS < >\ll'\K\r.ll 



gg 



p 1 


1 B 1 


1 1 


T Y 


(, R 


Oil 


» S 




















Average No 


t>i Lesions in 


Family 








I.oc; 


1 Ei 


presaions 




















( 


I Dental 


Inf. 


ctions 


















22 












c 
co 


3 




i 














E 

r 








1 






1 

CO 




CO 






be c 
C '<r. 


■ 
7 


3 
B 


ro 




> 


to 

c 

u 
ii 


.Is 

4> 


u 

3 £ 


3 £ 


C/5 

CU 


£ 






■8 


refyi 
nden 




-C 


u 


i 


B 


c 


D. 


o £ 


O Qj 


CO 




a 


Q 


CO o 


-X 


— 


hg 


Z 


z 


;/) 


H c?> 


H ifi 


u 


£ 





~ 


K U 


1 08 


2 48 


1 35 


1 01 


5 37 


3 12 


1.94 


11.34 


16 35 


75 


23 


25 


75 


32 26 


27 


47 


13 


13 


47 


17 


13 


1 07 


2 07 


in 


40 


40 


60 


67 




73 


27 


60 


2 47 


93 


1 00 


4 20 


b 40 


80 


33 


33 


87 


33 20 


B 


3 00 


87 


1 20 


4 40 


1 87 


1.27 


9 60 


13 40 


67 


33 


40 


87 


33 20 


1 40 


4 07 


1 93 


1 27 


6 13 


3 73 


2.00 


15 JO 


20 53 


93 


20 


27 


80 


40 33 


1.07 


3 40 


2 00 


1.80 


7 00 


5 20 


2 07 


17 20 


22 53 


80 


20 


20 


80 


27 33 


3 13 


7 07 


5 13 


3 33 


16.93 


7 07 


7.60 


32 20 


50 27 


93 








87 


7 67 



mild, inherited susceptibility one side strong, and inherited sus- 
ceptibility both sides strong. The figures for these groups are 
shown in Figure 42, from which it will be noted in the last two 
columns under "Average No. of Lesions in Family" that the total 
severe rheumatic group lesions per family in the non-susceptibil- 
ity or absent group is reduced to 1.07, and the severe and mild 
rheumatic group lesions to 2.07; the group with acquired suscep- 
tibility, severe lesions, 4.2 severe and mild lesions 6.4; inherited 
susceptibility, mild one side of ancestry, severe 9.6, severe and 
mild 13.4; inherited both sides mild, severe 15.3, severe and mild 
lesions 20.5; inherited one side strong, severe lesions 17.2, severe 
and mild lesions 22.53; inherited two sides strong, severe lesions 
32.2, severe and mild lesions 50.27. 

The above is an analysis of the ancestry on the premise of the 
patient's condition. When we reverse this and use the ancestry 
as the basis on which to judge the progeny, results are quite as 
striking, as shown in Figure 43; from which it will be seen that 
in eight families with an average of 7.3 children per family with 
no apparent susceptibility, the average number of children 
affected per family was .63; which means that during the entire 
lifetime up to the time of the record less than one child per family 
had shown at any time a rheumatic group lesion. The percentage 



100 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 



MENDELIAN FACTORS 



Relative number of children affected in families when 

(a) Patient has absent susceptibility. 

(b) Patient has acquired susceptibility. 

(c) Patient has strongly inherited susceptibility. 



No. of 
cases 



(a) 8 

(b) 8 

(c) 8 



Average No. 
of children 
per family 

7.3 

7.2 
9.0 



Average No. 

of children 

per family 

affected 

0.63 

1.2 

4.0 



Percent of 
children 
affected 

9%.... 
17%.... 
44%.... 



Susceptibility absent 
" acquired 

" inherited 



Figure 43. 



A PROGRESSIVE STUDY OF THE RELATION OF THE SUSCEPTIBILITY 
FACTOR OF INDIVIDUAL PATIENTS TO THAT OF THEIR RELATIVES. 







S 

3 


(Applied Mendelismi 


Average No. ol 


In- 


Percentage of In- 






s 


dividuals 


Per Fam- 


dividuals 


with: 




o 


ily Who 


tfave 


Had 










O 






Lesions In: 




























CD C 

o u 

S § 


CD 








</> 






Group 


1 

O 


u 

en 3 


3 
in 

H 

CD 
> 


+-) 


u 

a 
u 

H 
>> 

cd 

£ c 
.>-o 

"555 

CD 


CD 

o 

CD 
j> 

'cfi 
C 


j3 

C 

cd 

Q 

e 

T3.2 

aj +■> 
v. u 


.2 

U 

O 

e 



c 






<U'3> 


E-c 


u 


ra 


MX) 




~u £! 


■£ 




d 
2 


> CD 


oK 

r— ^v — • 


£ 


X 


S g 




3£ 


CD 

Oh 


1 Dental Patients with 




















No Developed Sus- 




















ceptibility 


35 


3.7 


11 


1.0 


5 


1.0 


519? 


58% 


23% 


2 Dental Patients with 


12 


4.7 


13 


1.3 


6 


1.6 


91' ( 


75', 


33' c 


an Apparently Ac- 




















quired Susceptibility 


27 


7.7 


2 2 


2 


12 


2 2 


78'; 


48% 


26% 


3 Dental Patients with 




















a Susceptibility and 




















with one or both Par- 




















ents acting as Car- 




















riers Only 


16 


10 


3.8 


2 3 


19 


23 


81%, 


44% 


25% 


4 Dental Patients with 




















a Susceptibility and 




















with only One Side of 




















Ancestry, including 




















the Parent Involved 


8 


13 6 


5.2 


3.4 


3 3 


2.1 


889? 


75' { 





5 Dental Patients with 




















a Susceptibility and 




















with Both Sides of 




















Ancestry, including 




















Both Parents In- 


7 


37 


12.4 


8.0 


9.0 


7.0 


100'^ 


86% 





volved 





















Figure 44. 



CHAP. l\ KKE HUMAN BEINGS COMPARABLE? KM 

of all ilk 1 children affected in this group was 9. In the second 
series oi eight families with an average number of children per 
family of 7.2, where there was what we have termed an acquired 
susceptibility, the average number of children affected per family 
was 1.2 or a total for this group of 17' , . In a third group of eight 
families with an average number of children per family of 9, the 
average number of children affected per family was 1, and the 
percentage of affected children in this group jumps to 44. 

Realizing how critical one must be of his findings when 
searching for fundamental new truths because of the danger of 
seeing the thing one is looking for, I have made or have had made 
several separate and independent studies for the purpose of check- 
ing one against the other. The individual compiling the last 
group of 681 selected cases not only did not know the content of 
the previous compilation, but did not even know that one had 
been made. She was kept in ignorance of this fact for her own 
protection, and it is exceedingly important to find that in 
several particulars those records analyzed in 1919 furnish totals 
which are strikingly similar to those recently completed. ( 1922) 

Figure 44 shows an analysis of five different groups slightly 
differently selected as follows: Group No. 1, Dental patients 
with no developed rheumatic group susceptibility; Group No. 2, 
Dental patients with an apparently acquired susceptibility; 
Group No. 3, Dental patients with a susceptibility, and with one 
or both parents acting as carriers only (parents' ancestry in- 
volved, but parents not yet) ; Group No. 4, Dental patients with 
susceptibility with only one side of the ancestry, including that 
parent, involved; Group No. 5, Dental patients with a suscepti- 
bility, and with both sides of the ancestry, including both parents, 
involved. 

Among the many similarities, note that in the first group of 35 
non-susceptibles the average total severe rheumatic group lesions 
per family is 3.7; whereas, in the recent analysis of 102 non-sus- 
ceptibles, this is shown to be 4.2; (See Figure 41) and in Figure 
42, the 15 strongly absent cases, 1.07. (See column "Total 
Severe" under "Average No. of Lesions in Family."] The cor- 
responding groups of acquired susceptibles in these three studies 
show in the figures of 1919 (Figure 44) 4.7 severe lesions and in 
Figure 42, 4.2 severe. Groups 3 and 4 of Figure 44 are not 
exactly comparable to groups 3, 4, and 5 of Figure 42, though 
quite similar in classification of individuals. Group 3, Figure 44 , 



102 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 



A STUDY OF SUSCEPTIBILITY OF VARIOUS GROUPS OF PATIENTS WITH RHEUMATIC LESIONS 
WHICH ARE APPARENTLY RELATED TO DENTAL FOCAL INFECTIONS 



Group 


a 

3 

o 

u 

P 

en 

1 
b 

6 
35 


bo 

C 

« 

be 
< 

19 
to 
85 


a) 

bo 
< 

be 
w 

\-i 

0) 

> 

< 


3 

jj re 

a) ai 

V) Q. 

o.o 

f— I cfi 
1 <D 

be 1 - 1 

2 y 
p'-S 

> 2 

< 6 


Percentage of Patients 

in Group Who Have Had 

Lesions In: 


Average No. of In- 
dividuals Per Fam- 
ily Who Have Had 
Lesions In: 


in 

<u 



as 

E-s 


Ifl 

<U 
3 
to 

H 
> 

L 

s 


3 

V 


o 

<D C 
bCT3 

3 £ 


en 

o ,-. 

3 E 

M 'J. 

OJ 3 

E-s 


V 

3 
H 
> 

0) 




u 
sj 

H >. 

(Ll 

CD c 

«5 

35 

bo TD 

Q § 


1 Dental Patients with No 
Developed Susceptibility 


46 


3.7 














11 


10 


5 


10 


2 Dental Patients with Rheu- 
matism Most Dominant in 
Patient and Family 


14 


17 
to 
55 


40 


14 8 


100% 


95% 


36% 


79% 


6 9 


2.8 


2 


3 3 


3 Dental Patients with Nerve 
Lesions Most Dominant in 
Patient and Family 


3 


31 
to 
42 


35 


16 


67% 


100% 


33% 


100% 


4 3 


6 


3 3 


3 


4 Dental Patients with Lesions 
in Digestive Tract and Kidney 
Most Dominant in Patient 
and Family 


8 


12 
to 
56 


40 


17.4 


50% 


88% 


50% 


100% 


4 1 


2 9 


3 3 


7 3 


5 Dental Patients with Lesions 
of Rheumatism and Nerves 
Most Dominant in Patient 
and Family 


9 


26 
to 
63 


44 


18 3 


100% 


100% 


44% 


78% 


6 4 


5.7 


2 6 


3.7 


6 Appendix Infections in Child- 
ren and Grandchildren where 
Lesion was Dominant in 
One Side of Ancestry 


3 


12 
to 
48 


31 


22 

(23.3)x 


67% 


67% 


67% 


100% 


6 

(8.3 


4 
4 


3 3 
3 3 


8.7 
9.7)x 


7 Dental Patients with Lesions 
of Rheumatism and Heart 
Most Dominant in Patient 
and Family 


14 


18 


42 


24 


100% 


93% 


100% 


71% 


7 4 


4 4 


6 9 


3 5 


8 Dental Patients with Heart 
Lesions Dominant in Patient 
and Family 


7 


30 


43 


28.2 


71% 


86% 


100% 


86% 


7 


6 1 


9 7 


5.0 


9 Dental Patients with Rheu- 
matism, Nerves, Digestive 
Tract and Kidney Most 
Dominant in Patient and 
Family 
x — Children included. 


6 


21 


35 


27.8 


100% 


100% 


50% 


100% 


9 2 


7.7 


3.7 


7.7 



Figure 45. 



CHAP l\ VRE HUMAN BEINGS COMPARABLE 103 

has severe rheumatic group lesions 10 per family, and Group 3, 
[•'mure 42, has 9.6; Group 4, Figure 44, 13.6, Groups I and 
5, Figure 42, 15.3 and 17.2 respectively; Figure 44, Group 5, 

strong inherited susceptibility from both sides, 37, and Figure 12, 
Group 6, similar strong inheritance, 32.2. 

Similarly, Figure 45 made in 1919, in which the dominance 
in its relation to the particular type of tissue is involved, shows 
progressively percentages beginning with 3.7 for non-suscepti- 
bility and increasing to 27.8 for susceptibility to lesions in several 
types of tissues. The average total severe rheumatic group 
lesions per family for the group with absent susceptibility, 
marked "No Susceptibility," is 3.7; those with rheumatism the 
most dominant in the patient and family, 14.8; nerve lesions 
most dominant in patient and family, 16; digestive tract and 
kidney, 17.4; a combination of muscle and nerve involvements 
as rheumatism and neuritis, 18; appendix infections where lesion 
was dominant in one side of the ancestry, 22; where rheumatism 
and heart affections were both expressed in the family, 24 ; heart 
affections alone dominant in the family 28.2; and where a com- 
bination of affections as rheumatism, nerves, digestive tract, and 
kidney, were all dominant in the family, 27.8. 

A further comparison of data developed in the two series of 
studies is of value. At that time one hundred consecutive fami- 
lies were studied (See Figure 46) and the ratios of lesions in 
various types of tissue recorded for comparison. The recent 
analysis (1922) of seven hundred cases (See Figure 41) se- 
lected from dental practice (as distinguished from individuals 
studied under other conditions to be discussed later) , when com- 
pared with the former determinations of 1919, reveals the follow- 
ing remarkable similarity of figures: Joints and muscles, former, 
Figure 45, 65%, recent, Figure 41, 63%; Nerves, former 
70%, recent 81% (we are recognizing more nerve lesions than 
formerly with increased information); Heart, former 28%, 
recent 26%; Internal Organs, former 61%, recent 60%; Tonsils, 
former 62%, recent 53%. 

A comparison of the severity and frequency of lesions in the 
two sexes, when compared in the two sheets of studies, again 
repeats an important similarity. In the former studies of one 
hundred patients with severe lesions, 75% were females and 25% 
were males; and in the recent study of 681 cases, 71% were 
females and 29% were males. In this connection, it is interesting 



104 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 



COMPARISONS OF TWO SEPARATE STUDIES 



Relative Prevalence of the Following Lesions in Affected Patients 



Summary 

Made In 



No. of Affected 
Patients 



1919 
1922 



100 
681 



Joints and 

Muscles 

( Rheumatism 



Nerves 



65% 
63% 



70', 
81', 



Heart 



28' i 
26% 



Internal 
Organs 



6195 

60% 



Tonsils 



62% 
53% 



FIGURE 16. 



DOMINANCE OF SPECIAL TISSUE LESION IN BOTH PATIENTS AND FAMILIES (TENi 



Group 
Rheumatism 


JV 
TO 

"o 

6 
2 


en 

"to 

s 

6 
2 


No. of Lesions in 
Ten Patients 


No. of 


Lesions in 


"amilies 






Local Expressions 
of Dental Infections 


'tfl 

C 

O 

h 


Rheumatism 

Heart 

Neck 

Nerves 

Internal Organs 

Special Tissues 


C 

o 
h 


S 

TO 

s 

p 


X 


Neck 
Nerves 


ca 

tx 

C 
c 

u 

C 


t/3 
0) 

CO 

H 

Q. 


Total 


Caries 
PeriodontoL'hsu 


Open 
Locked 

Rarefying 
Condensing 


u 

> 
0) 

CD 


2 

i 

<u 
u 

> 

C/3 


2 


8 


5 


10 2 6 4 4 3 


8 


59 


7 


9, 19 


19 


10 


104 


131 


9 1 


16 2 3 


Heart 


3 


7 


7 


6 10 5 7 3 8 


12 


24 


57 


6 25 


13 


19 


121 


156 


10 1 


2 8 3 5 


^ Nerves 


2 


8 


5 


6 2 7 10 7 7 


10 


15 


9 


10 142 


28 


19 


180 


233 


9 3 


3 9 5 5 


Internal Organs 


2 


8 


6 


4 6 9 10 6 


6 


13 


9 


10 30 


90 


12 


136 


170 


7 3 


3 7 4 3 



Type of susceptibility — inherited. 



Figure 4< 



MENDELIAN FACTORS 



Cases 



42 



Average 
No. of 

children 

per 
family 



Average 

No. of 

children 

affected 



Fathers 
affected 



76' , 



Fathers' 
Relatives 
affected 



6K ( 



Mothers 
affected 



50% 



Mothers' 
Relatives 
affected 



55', 



Dominance 

in 

ancestrv 



6K, 



Dominance 

in 

children 



51% 



Mendelism 



Figure 48. 



CHAP, n UlE HUMAN BEINGS COMPARABLE? L05 

to note that in the progressive classification of cases from ab- 
sence of susceptibility through mild to severe, the ratio of males 
to females keeps changing in a definite and geometric proportion; 
whereas, in the group Figure 42 of absent susceptibility, tin 

ratio of males to females in the eases selected at random was 
53* , males to 17' J females; acquired susceptibility, 40* [ males 
and (if)' j females; inherited susceptibility, mild one side only, 
33' , males and 67^ females; inherited strong one side, 27' , 
males and 73' J females; inherited two sides mild, 20' , males 
and 80' j females; inherited two sides strong, 7' \ males and 93* ', 
females. This last group represents persons with very severe 
lesions. iThis tells a tragic story which is discussed later in the 
chapter on Overloads and is largely a record of the terrific charge 
that Nature has made against motherhood, i 

An analysis of these data throws a very important new light 
on the nature of an inherited susceptibility, which is augmented 
by careful application of these observations in clinical practice. 
We have thought of susceptibility in terms of a systemic de- 
fense. After we make an analysis, for example, of hearts in 681 
selected cases, consecutive except that there have been elimi- 
nated all cases in which we could not secure a sufficiently com- 
plete record, in these we find that 26* { of the patients, approxi- 
mately 1 in 4, have some heart disturbance. This in itself is a 
tragic revelation, especially when we contemplate that 1 in 10 
of the deaths of all ages in modern civilized communities is from 
heart affection. An examination of the heart column in Figure 
42 shows a progressive column of ratios of patients with heart 
involvements; from in Group 1, those without streptococcal 
susceptibility, 20 r ( in the acquired group, 13 r \ inherited one 
side mild, 27 r ( inherited one side strong, 40 r r inherited two sides 
mild, to 80 ( \ inherited two sides strong. Comparing this with 
the data in Figure 45 under the column "Percentage of pa- 
tients in group who have had lesions in various tissues," we find 
that the percentage starting in Group 1 as 0, advances pro- 
gressively so that in the group in which the heart was dominant 
in the family, in seven families which were studied at that time, 
and many more of which have been added, the ratio is 100' , . 
While these were unusually severe instances of susceptibility to 
heart lesion, it is most striking to see how frequently the sus- 
ceptibility to heart is dominant throughout the family with com- 
plete absence of other rheumatic group lesions; and, similarly, 



106 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

kidney, muscles and joints, digestive tract, and special tissues, 
each dominant in the particular family group while all other tis- 
sues remain very low or completely absent. This is strikingly 
revealed in a section of Figure 42 entitled "Average No. 
of Lesions in Family" and in Figures 43 and 44, and in the totals of 
Figure 41. It is, however, true, as revealed in all of the charts, 
that the heart or some other tissue may be dominant by inheri- 
tance and there may be an acquired susceptibility for some other 
tissue, which other tissue is in the majority of cases the nervous 
system. 

Contrary to our expectations, we do not find that the inheri- 
tance of a susceptibility to rheumatism necessarily carried with 
it a susceptibility to heart or vice versa. This is strikingly 
illustrated in Figure 47 which shows many instances of heart's 
being dominant in the family and no rheumatism; and likewise, 
rheumatism dominant in the family and no cases of heart. In a 
study of the relation of other infections, such as syphilis, to 
heart involvements we show that this is an important factor as a 
source of heart lesions and that these individuals frequently, if 
not generally, have distinctive characteristics aside from their 
history and Wasserman reactions. The data in the chart in Fig- 
ure 47 is exceedingly important because it shows that in forty 
selected families where the chief lesion of the patients studied 
was one of the four following — rheumatism, heart, nerves, or in- 
ternal organs — in every instance that lesion by far outnumbered 
all others in the individuals constituting the patients' relatives, 
as, for example, in ten patients affected the number of instances 
of rheumatism in other members of the family was 59, whereas 
no other lesion of the rheumatic group exceeded 19. Where 
heart was the chief lesion of the patient there were 57 cases of 
heart in the immediate family and no other lesion exceeded 25. 
Where nerve lesions were the chief lesions in the patient there 
were 142 instances of severe nerve lesions in the family, whereas 
no other lesion exceeded 28; and where the lesion of the patient 
was in the internal organs there were 90 instances of lesions in 
the internal organs of other members of the family, whereas no 
other tissue exceeded 30. 

When we take the total number of heart cases in 681 family 
groups, we find it to be 916 hearts, or an average of 1.35 per fam- 
ily. An actual count of the families having at least one case of 
heart reveals that of the 681 families, only 413 have any heart 



CHAP l\ IRE HUMAN BEINGS C0MPARABL1 107 

lesions, an average of 2.2 per family; and of these, 100 families 
had over half of the Lesions. An analysis of the families included 
in Figure 42 shows that in each of the six groups of fifteen 
families each, there is not an instance where the patient being 
studied had developed a heart lesion, where there was not a 
record of a heart lesion in the brothers or sisters, or fathers' and 
mothers' families; and in practically all instances where the num- 
ber of hearts per family group is greater than the average lor the 
entire group, the patient is recorded as having a heart lesion, and 
the severity of the heart lesion is in striking proportion to the 
dominance of the lesion in the family. The groups of fifteen in 
Figure 42 show more striking conditions than the average. 
Similarly and quite as strikingly, we might study kidney, joint 
tissues, and other tissues, though not necessarily the nerve tissues 
which apparently may have a susceptibility by inheritance or be 
an acquired factor. 

An analysis of the data has been made to see the evidence of 
mendelism. This is shown in Figure 48. In 42 cases of marked 
susceptibility, the average number of children per family was 5. 
The average number of children affected was 2.7, which you will 
note is 54 r ( ' . In these 42 families, 61% of the two ancestral 
families had been afflicted with severe rheumatic group lesions. 
The dominance, therefore, will be seen to be 88% of that in the 
preceding generations, which we may take as a factor of mendel- 
ism. 

It will be of interest to note the relation of inherited suscepti- 
bility to both the mothers' and the fathers' sides of the ancestry. In 
the patients, 73 r ( showed inheritance of the chief severe lesion, and 
21 c [ an acquired susceptibility. Of the inherited. 44% were singly, 
that is from one ancestral branch ; only 29% from both sides of 
the ancestry. Of the singly inherited, 23% showed inheritance 
through the maternal side, and 21% through the paternal side. 

Where the susceptibility was apparently an inheritance qual- 
ity, we found that in involvements of joints and muscles, there 
were 4 males to 5 females; nerve tissues, 2 males to 3 females; 
heart, 3 males to 4 females; digestive tract and kidney, 4 males 
to 5 females; nervous system, 3 males to 5 females; making a 
general average of 3 males to 4 females. One of the most striking 
results of this study has been to find that when an acquired sus- 
ceptibility obtains — in other words, where the individual with 



108 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

normally an ample defense has been overloaded — in the great 
majority of individuals the break came in the nervous system. 
Overloaded tissues in general tend to break and become a prey to 
streptococcal infection or toxic irritation. 

Reading downward in most of the columns of the various charts 
you will see evidences of a progression, some of which are very 
striking. We shall later discuss in Chapter 21 the forces which 
tend to make tissues susceptible, which are not limited to inherit- 
ance but have to do with injury and overload of various types. 
This extensive study of the characteristics and relationships be- 
tween systemic involvements and individual susceptibilities has 
brought out many other very striking new facts, such as the type 
of the tissue reaction about apical involvements in relation to the 
systemic susceptibilities, the relationships of susceptibilities to 
dental caries and periodontoclasia (pyorrhea alveolaris), which 
have been made the subjects of special researches and will be dis- 
cussed in this order in the three succeeding chapters. 

SUMMARY AND INTERPRETATION. 

To summarize: 

(1) The evidence that we have secured to date on the problem 
of the variations in susceptibility, while not sufficient for a final 
statement, is ample to suggest what will be a much safer interpre- 
tation until further data are available. To recapitulate briefly, in- 
dividuals instead of being similar and therefore comparable in 
their susceptibilities to infection, divide themselves into three 
groups: Non-susceptibles, acquired susceptibles, and inherited 
susceptibles. 

(2) The tendency of an individual to develop both general and 
special systemic involvements has a direct relation with, and 
proportion to, the susceptibility of the various members of that 
family circle. 

We would therefore restate the fourth fundamental as follows : 

Individuals as a whole do not react sufficiently simi- 
larly to justify the premise that they could all be 
judged by the same standards and therefore be con- 
sidered comparable; that individuals can be classi- 
fied into groups, the members of which are suffi- 
ciently similar to be judged by the same general 
standards, and they may therefore be considered 
comparable. 



CHAPTER V. 

RELATIONSHIPS BETWEEN LOCAL AND SYSTEMIC 

REACTIONS. 

PROBLEM: Is it true, as generally presumed, that there arc 
no distinguishing characteristics which relate the type of 
local periapical reaction to the nature and extent of systemic 
reaction? 

INTRODUCTION. 

Problem No. 3 was a study of the local characteristics of the 
periapical lesions as they develop in various individuals, and 
revealed (a) that infection may or may not produce extensive 
absorption in bone, and (b) that a given or similar dental infec- 
tion will not necessarily express itself in the local tissues of the 
mouth approximately the same in all people; that these expres- 
sions tend to be of three different types which we have as a group- 
ing for individuals, and that the individuals of this group there- 
fore are comparable in this regard. The differentiating charac- 
teristic of these three groups was that the first had very exten- 
sive absorption of alveolar bone about the apex of an infected 
tooth, a marked rarefying osteitis; the second was similar except 
that it tended to have a zone of condensing osteitis surrounding 
the zone of rarefying osteitis; and the third with a similar quan- 
tity of infection had a relatively limited area of rarefying osteitis 
frequently surrounded by a condensing osteitis. 

Problem No. 4, Chapter 4, was an analysis of the presump- 
tion that all individuals are comparable. The research data 
strongly indicated that they are not ; that while there is a varia- 
tion through a wide range, that variation still permits of individ- 
uals' being roughly grouped into three general classes with regard 
to the presence or absence of systemic lesions of the types which 
we have classified as the rheumatic group affections frequently, 
if net generally, produced by streptococcal invasion. 

This research, which we have designated as Problem No. 5, is 
a study to determine whether or not there is a relationship be- 
tween the groupings disclosed in the researches of these last two 
chapters. This problem may then be stated briefly as "The 
Relationships between Local and Systemic Reactions". 

109 



110 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 
EXPERIMENTAL AND DISCUSSION. 

Since, according to the presumption, all individuals are similar, 
and since dental infections are entirely dependent for their char- 
acteristics upon the type of organism which has chanced to secure 
access, therefore there are no characteristics of the local tissue 
pathology which are related to the degree of susceptibility or 
nature of systemic involvement. Our problem more specifically 
stated is "What relationship, if any, exists between the forces 
which make individuals group with regard to their local tissue 
reactions about infected teeth, to those forces which make them 
group with regard to their systemic involvements into absent 
susceptibility, acquired susceptibility, and inherited suscepti- 
bility." 

In order to determine this we have made a very careful study 
of the local tissue reactions found about the teeth in the 1400 
cases from which the 681 cases have been selected as being suffi- 
ciently complete in detail to be worthy of comparison. Our 
charts have been provided with spaces for recording in detail the 
type of dental pathology found in the various cases. In Figure 
49 (also shown in Figure 42 of Chapter 4) there is a progres- 
sive increase in the dominance of rheumatic group lesions with 
the dominance of the inheritance, heart lesions, for example in- 
creasing from to 80 per cent, and lesions of other tissues increas- 
ing in about the same proportion. The last division shows under 
"Local Expressions of Dental Infections" that open dental infec- 
tions, by which we mean those that have a communication with 
the mouth cavity, were found present in 40 per cent of the indi- 
viduals of the absent group, 33 per cent of the acquired group, 
40 per cent inherited one side mild, 27 per cent inherited two 
sides mild, 20 per cent inherited one side strong, and inherited 
two sides strong. Locked infections increase through these 
groups from 60 per cent to 87 per cent. Rarefying osteitis de- 
creases from 67 per cent in the class of absent susceptibility to 
7 per cent in the inherited susceptibility two sides strong. Con- 
densing osteitis is present in per cent of cases of the class of 
absent susceptibility and increases progressively to 67 per cent 
inherited two sides strong. It is significant that the individuals 
making these figures had not the slightest conception of what 
they were for or what information was going to be developed. 

The significance of this important new truth cannot be realized 
suddenly. It is only by seeing patient after patient of these 



CHAP \ RELATIONS BETWEEN LOCAJ \ND SYSTEMIC REACTIONS HI 



RELATION OF LOCAL STRUCT! RAL CHANGES It) SYSTEMIC 
SUSCEPTIBILITY 



Susceptibility 
Class 


Age 


M 


F 


•j) 


g 

ft 

e 






SB 


c 

C 






7 


be 
c 


- 
c 

B 

D 










■SI 


3 


u. 


.x 


> 


C 




a 




8 


T3 










C 

o 




S 


u 


D 




a. 


g 


u 


S3 


C 

B 










H 


OS 


K 


2 


£ 




C/5 





Z. 


U 


Groups of 15 






























Absent 


40.7 


53 


47 


27 


13 





13 


13 


7 


7 


40 


60 


67 





Acquired 


17 9 


40 


60 


40 


47 


20 


53 


87 


53 


53 


33 


87 


33 


20 


Inherited 


43 4 


33 


67 


53 


93 


13 


60 


80 


17 


47 


10 


87 


33 


20 


1 side mild 






























Inherited 


40 9 


20 


80 


60 


87 


40 


73 


80 


67 


73 


27 


80 


40 


33 


2 sides mild 






























Inherited 


39.4 


27 


73 


17 


93 


27 


80 


100 


67 


87 


20 


80 


27 


33 


1 side strong 






























Inherited 


33 9 


7 


93 


80 


73 


80 


93 


100 


93 


87 





87 


7 


67 


2 sides strong 































Figure 49. 

various classes and observing how constantly the local reaction 
about the teeth corresponds with phases of the systemic suscep- 
tibility to rheumatic group lesions that one visualizes its full sig- 
nificance. When we compare these data with the charts shown in 
Figures 38, 39, and 40, of Chapter No. 3, we find that the individ- 
uals whose cases were found to be typical of the type of structural 
change which we have represented in Figure 38, all belong to the 
class which we have referred to as having absent susceptibility. 
The structural change in alveolar bone about infected teeth of 
this group is that of an extensive alveolar absorption as a rarefy- 
ing osteitis diffusing into the medullary spaces without condens- 
ing osteitis. The group represented in Figure 39 corresponds 
and is, we find, the same group of individuals that make up our 
lists, when studied from the standpoint of systemic involvement, 
of those of acquired susceptibility. They have evidence of an 
extensive rarefying osteitis surrounded by a zone of condensing 
osteitis, sometimes thin, sometimes of considerable depth. And, 
similarly, the group which we have expressed in Figure 40 as hav- 
ing a very limited zone of rarefying osteitis in comparison with 
the quantity of infection, surrounded by a blurring of the medul- 
lary spaces or with a condensing osteitis diffusing into a general 



112 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

bone condensation, corresponds with the group of strongly in- 
herited susceptibility to rheumatic group lesions. 

To be more specific, Figure 50 shows the condition in the 
mouth (as revealed by the roentgenograms of two individuals 
from each of the following groups : A and B, absent susceptibility ; 
C and D, acquired susceptibility; E and F, mildly inherited sus- 
ceptibility; G and H, strongly inherited susceptibility;) to be as 
follows: There is very extensive alveolar destruction about in- 
fected roots, particularly the first molar. This includes also a 
marked tendency to root absorption, with the result that the 
mesial root of the molar is practically obliterated. There was 
a fistula over each one of these three teeth, with exudate oozing 
on compression. This man, fifty-two years of age, was physically 
in excellent condition with but one exception: limitation of the 
use of his eyes in reading, not sufficient to produce lesions but 
requiring glasses. After the removal of his dental infections 
which were extensive, he found he could read without limitation 
and that without his glasses. Not only was his system excellent 
and free from rheumatic group lesions notwithstanding this 
abundant infection, but he had seven brothers no one of whom 
had ever suffered from any of the rheumatic group lesions, and 
three sisters none of whom had suffered from any of the rheu- 
matic group lesions. A study of his father and the father's 
brothers and sisters, and the mother and her brothers and sisters, 
reveals but one mild instance of a suspected rheumatic group 
lesion on either side of the ancestry, including the grandparents 
on both sides. This is clearly a case of absent susceptibility. 

In Figure 50-B showing extensive alveolar absorption about the 
apices of the roots of a molar and bicuspid, we have a condition 
in the mouth of a man of twenty-five years of age. Note the 
extensive absorption of bone and tendency to absorption of root 
ends. Physically, this man has scarcely known a limitation. 
Material aspirated from an apical area showed many giant cells, 
which particular cell we have only found in cases of very high 
defense where there is absorption of root apices. His physical 
classification is also absent susceptibility. His family history is 
as follows : He has not had during his lifetime a single break of 
the rheumatic group lesions. His brother and four sisters have 
also been entirely free. His father is fifty years of age and has not 
had a symptom of any of the rheumatic group lesions, nor have 
any of the father's three brothers or two sisters, his father's 



CHAP. \ RELATIONS BETWEEN LCCA1 VND SYSTEMIC REACTIONS 113 




Fuii'KEoO. Typical illustrations of the local reactions in the different groups. 



father and mother living to ninety years of age each. His mother 
at fifty-two years of age has had hardening of the arteries and her 
father had some rheumatism. Otherwise the record is perfectly 
clear on the mother's side. The mother's mother is living and 
very strong at seventy-five. ♦ 

In Figure 50-C we have a patient with very extensive absorp- 
tion of alveolar bone but with a zone of condensed bone surround- 
ing the immediate zone of rarefaction at the apex and about the 
bicuspid root. This patient has been free from rheumatic group 
lesions during his lifetime until recently when he has developed 
neuritis. He is sixty-seven years of age, has had five brothers and 
six sisters, one of the latter being ninety years of age. His father 
died of typhoid at fifty-eight and his father's father and mother 
both lived to ninety. His mother died at ninety-two and her 
mother at ninety-two. There has not been a single case of rheu- 
matic group lesion on either side of the ancestry. This man's 
classification is clearly one of an acquired susceptibility. 

In Figure 50-D we see the local dental expression to be one of 
quite extensive alveolar absorption above the right central which 
shows a record of condensing osteitis surrounding the rarefying. 
Physically, the patient presented with pain of recent develop- 
ment in his right shoulder and right knee. He has had three brothers 
and three sisters. One of the former has had a heart involvement. 



1 14 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

Otherwise the brothers and sisters have been free from rheumatic 
group lesions. His father died at sixty of a stroke and the father's 
side of the ancestry with three brothers and three sisters was free 
from rheumatic group lesions, his father's mother dying at eighty- 
five. The patient's mother is living at seventy-seven, is in excel- 
lent health, and has never been ill except one attack of pneumonia 
and some asthma. His mother's father died at eighty and her 
mother at eighty-nine, and these with her four brothers and six 
sisters were entirely free from rheumatic group lesions. There is 
a possibility that the heart involvement of his brother, though 
not accompanied by rheumatism, may have had some relation to 
his own rheumatic development, but we assume not since there is 
no evidence of it elsewhere in the family. We would therefore 
classify this as one of an acquired susceptibility. 

In Figure 50-E the dental pathology as revealed in this case 
shows much less absorption of the alveolar bone surrounding an 
apparently unfilled root, there being no root filling in the mesial 
canal of the third molar and not as extensive absorption about the 
roots of the first molar as we should expect. A study of this 
patient's susceptibility reveals that he has had mild attacks of 
rheumatism and some slight evidence of neuritis. He has one 
sister. She has had mild rheumatism. His father died at seventy 
of anemia and has a history of mild rheumatism. His father's 
father died at seventy-six of kidney and heart involvement, 
probably related to the rheumatic susceptibility; his father's 
mother at eighty-six with a definite history of rheumatism. His 
mother is living at seventy-six with a definite history of rheuma- 
tism and gall-stones. The mother's mother had heart and kidney 
involvement and the mother's sister very severe rheumatism and 
heart involvement. There has therefore been a very definite 
tendency to rheumatism in this family ; and while it has been on 
both sides, neither of the parents has suffered severely. We 
would therefore record it as a mildly inherited susceptibility. 

Figure 50-F shows three lower incisors, one of which has a 
putrescent pulp without root filling, yet neither it nor the adjoin- 
ing teeth show extensive absorption. This patient is fifty-five 
years of age and presents with mild neuritis and rheumatism of 
recent development in his hands. Otherwise he has been entirely 
clear during his lifetime. His two brothers and a sister have not 
had disturbances. His father died at seventy-nine, having had 
severe attacks of rheumatism and neuritis. His father's father 



CHAP. \ RELATIONS BETWEEN LOCAL AND SYSTEMK REACTIONS L15 

died at seventy-four. The patient's mother died of pneumonia 
at thirty-seven, the mother's father at sixty-six, the mother's 
mother at eighty-four, all without symptoms of rheumatic group 

lesions. Since there is a definite history of rheumatism and 
neuritis with the lather, not in other members of the ancestry 
and not previously in the patient, we would classify this as a case 
of mildly inherited susceptibility. 

Figure 50-G shows a lateral of a girl only twenty-three years of 
age. There has been a moderate absorption but no fistula and no 
local pain. She presents with quite severe rheumatism and severe 
lassitude. Even at the age of twenty-three she has had quite 
severe rheumatism, neuritis, nervous breakdown, and digestive 
disturbance. She has two brothers and four sisters. Each one 
of the six brothers and sisters has had rheumatism and each, 
like herself, has been operated for tonsils. Her brothers and 
sisters have also all had acute neuritis. Her father died at fifty- 
six, having had acute rheumatism and neuritis and acute digestive 
disturbance. His father died at eighty-one, having been a sufferer 
from rheumatism and neuritis. The father's mother had also 
suffered from rheumatism, neuritis, and digestive disturbance, as 
did also the father's brothers, three of whom and the patient had 
kidney involvement. The patient's mother is living at sixty-one 
but has suffered severely during her life from rheumatism, neuritis, 
and digestive disturbance. Her mother died at seventy, having 
suffered from these severely; and the mother's mother died at 
thirty-nine of acute rheumatism. The mother's brothers and 
sisters also suffered from rheumatism. We have, then, a family 
in which there have been sixteen cases of rheumatism, eight cases 
of acute digestive disturbance, and twelve cases of neuritis. This 
girl is breaking at twenty-three, not because of severe overload but 
in spite of the absence of severe overload. Of her two brothers 
and four sisters ranging in age from twenty-one to forty, everyone 
has similarly broken. Her father and mother began breaking 
seriously at about forty years of age and scarcely were free from 
disturbance thereafter. This girl by inheritance has an exceeding- 
ly marked susceptibility to not one but three at least of the severe 
rheumatic group lesions, involving muscles and joints, nerve 
tissues, and digestive tract tissues. We therefore record her case 
as one of strongly inherited susceptibility. 

The dental pathology as shown in Figure 50-H is very mislead- 



1 16 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

ing. There is very little evidence indeed of severe involvement 
of the root filled centrals; yet on extraction the root apices were 
badly discolored and therefore showed marked involvement 
though there was very little destruction of alveolar bone. She 
has presented with a very severe heart involvement and severe 
nervous breakdown. Her life was being despaired of. She had 
been troubled during that time a great deal with neuritis, nerve 
lesions, and heart involvement. Her age is forty-two. Her goiter 
has developed since the birth of her two children. She has had 
symptoms of rheumatism. She has had four brothers and four 
sisters, one brother and two sisters having had rheumatism. All 
four of her sisters have had severe nervous breakdowns as has also 
one brother. One sister has a severe heart lesion. Her father 
died at seventy-five of rheumatism and heart involvement. 
Her father's father died at forty, and three of her father's 
brothers and her father's sister all died of heart involvement. 
Her mother died of heart involvement at seventy-eight, having 
suffered severely from nervous breakdown and rheumatism. 
This patient has shown a marked susceptibility to these lesions 
during her lifetime, as have also her brothers and sisters and both 
sides of the ancestry. We would therefore classify her case as 
one of strongly inherited susceptibility. 

If, now, we will review these four groups, we find the following: 
The two individuals of the first group (A and B) have never yet 
had any of the rheumatic group lesions notwithstanding various 
overloads, nor did the members of their families or their ancestries. 
They therefore classify readily as having an absent susceptibility. 
C and D had a history similar, in general, so far as they them- 
selves and their ancestry were concerned except that they 
have lately broken. With each there has been a distinct physical 
overload of overwork. The development of their rheumatic 
group lesions has been a recent, though quite severe, disturbance. 
With the removal of the dental infections without a change in the 
overload of business cares, their conditions have cleared up com- 
pletely and promptly. E and F are two patients who have de- 
veloped acute rheumatic group lesions as rheumatism, which dis- 
turbances were definitely present in the ancestry. They are 
therefore classified as mildly inherited susceptibility. With 
removal of their dental infections they both had complete relief 
from their rheumatic disturbances notwithstanding they have 
maintained very busv business careers, which, no doubt, had 



( HAP V RE] VTIONSB] HVEEN 1XH \\ ANDSYSTEMK REA< I IONS 117 

contributed to their breaking, G and II are two cases of severe 
break with rheumatic group lesions that have tended to develop 
for some time, which lesions are very strongly present in the 

other members of the family and ancestry. They are accordingly 
classified as strongly inherited susceptibility. Each has shown 
very marked improvement with removal of the dental infections. 
The latter has taken up her home duties again as a mother and 
the management of a large home and is enjoying excellent health. 

The question of prognosis in these various cases will be dis- 
cussed in detail later. It will, however, readily be seen that the 
prognosis becomes less and less favorable for complete relief and 
freedom as the condition gets to be more strongly an inherited 
quality. This matter is discussed in detail in other chapters. 

If, then, we will take a single tooth, let us say a lateral with all 
the infection of a putrescent pulp, and follow it through these 
different groups, we will see in detail the difference in the local 
structural pathology as well as in the physical systemic reactions. 
This we have done in Chapter 12 while discussing the relation 
of the quantity of absorption to the danger. 

It is exceedingly significant that when we picked out a group of 
individuals expressing each of the different classes from the stand- 
point of a structural change about the teeth, and again made 
groups typically characteristic, and strongly so, of the different 
groups or classes on the basis of their systemic susceptibility, we 
were amazed to find that out of the hundreds of cases from which 
we had selected these few typical illustrations we not only had 
similar individuals but in a very many cases we had the identical 
individuals that had been selected to illustrate a group on the 
other basis of classification. 

This one important new truth accounts for a very large part 
of the confusion amounting almost to bitter antagonism, that 
has existed in the medical and dental professions regarding 
whether or not dental infections are a serious factor in systemic 
involvements and degenerative diseases. It has been insisted by 
the group on one hand, on the basis of effect being in proportion 
to cause, that since the enormously large number, if not large 
percentage, of individuals presenting in the outpatient clinics of 
hospitals with the most abundant infections that could be found 
in any group, as evidenced by the quantity of pus flowing from 
broken dow r n and decayed teeth, do not have any systemic in- 
volvements, therefore, it cannot be true that dental infections 



118 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VCL. I 

are an important causative factor in the systemic involvements. 
If any individuals would be affected, surely this group would be 
and they are not. 

It now is demonstrated that the physical change about the root 
of the tooth is not a measure of the infection but a measure of the 
quantity and type of the reaction, not a factor primarily relating 
to the invading organism which is inside the infected tooth but a 
factor primarily relating to the activity of the defense of the in- 
dividual ; and when seen in this light, this whole confusion ceases 
to be a paradox and is completely intelligible. The individuals 
having the extensive rarefactions have an active mechanism of 
defense, which for them establishes an adequate quarantine 
immediately about the tooth. So long as that quarantine is 
maintained there is an extensive zone of rarefaction with little 
tendency to condensation of bone about this rarefying area. The 
vascularization is excellent. This also explains why these individ- 
uals without systemic rheumatic expressions tend continually to 
have alveolar fistulae. These are the individuals with absent 
susceptibility ; but when their defense is broken from the many 
causes that will be shown in subsequent chapters, they take on a 
condition which we have termed an acquired susceptibility. 
Incidentally, their local defense goes down; the quarantine is 
not maintained; a changed reaction takes place about the 
tooth with the change in local defense; there is a condensing 
osteitis surrounding the rarefying osteitis; the quarantine not 
being maintained about the tooth, the warfare must take 
place in other parts of the body. These individuals probably 
now for the first time have the organism passing extensively 
from their dental infections through their bodies, and in a 
sense it is the first time the tissues of their bodies have been 
exposed to this infection. After the overloads are removed they 
will tend strongly to come back to their normal which is high; 
but in the third group with the inherited low defense there 
always has been a struggle, there never has been a normal 
local quarantine, teeth never have had fistulae because there 
was never an ample local reaction the by-product of which 
would have been a fluid which must have an exit, spoken of as 
pus from a fistula; the warfare has always had to be carried 
on in the various tissues of the body rather than in the specially 
designed and developed tissue which Nature establishes for the 
purpose of maintaining the quarantine about the root apex. 



CHAP.\ RELATIONS BETWEEN LOCAJ IND SYSTEMIC REACTIONS 119 

This group is always in danger. Their type of local reaction 

about their teeth lias been what it has because of a lack of the 
capacity for a defensive reaction. 

SUMMARY AND CONCLUSIONS. 

The researches of this chapter have disclosed that individuals 
with a high systemic defense against rheumatic group lesions 
have also a very extensive zone of absorption about infected 
teeth; that with an overload these individuals tend to lose that 
high defense and develop the rheumatic group lesions, in which 
state they have less extensive absorption and a tendency to con- 
densing osteitis surrounding the already existing rarefying ostei- 
tis; or if a new dental infection develops at and during this period, 
there is much less absorption of alveolar bone than that which 
occurred prior to the development of this acquired susceptibility ; 
that the individuals of this group tend to come rapidly back to 
their high normal defense with the removal of their dental infec- 
tions; that in most instances there has been a combination of 
dental infections plus overload. We assume that other focal in- 
fections have precisely the same relationships to their overloads. 

In contrast to these two groups, all the members of which 
tended to belong to the absent susceptibility during the period of 
normal high resistance, we have found another group which we 
have subdivided into various degrees of inherited susceptibility, 
which susceptibility has been largely in proportion to the severity 
and dominance of the same expression in other members of the 
family and ancestry. The individuals of this group have had very 
much less alveolar absorption for a given dental infection, usually 
without a fistula. The teeth did not tend to become painful or 
tender as in the preceding groups. While there was relief from 
the acute systemic symptoms produced by the removal of the 
dental infections, there was a very marked tendency to recur- 
rence. This group was termed those with inherited susceptibility 
ranging from mild to severe. 

The prognosis was shown to be progressively more favorable 
with the absence of the inherited susceptibility factor. This new 
interpretation satisfactorily accounts for the clinical conditions 
and histories of the various types of individuals that are found in 
hospital clinics and private practice; and as the local defense is 
high, the absence of the systemic involvements prevails; and as 
the local defense is low, the prevalence of systemic involvements 
prevails. Therefore the individuals with the extensive areas of 



120 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

absorption with fistulae should be expected to be distinctly more 
safe than those with less effective local reaction, thus removing 
the paradox that has more than any other, or perhaps all other 
factors, blinded the professions to the role of dental infections in 
degenerative diseases. 

We would therefore restate the fundamental which expresses 
the relation of local to systemic disturbances as follows: 
Local dental pathology about an infected tooth has 
variations which make grouping and classification 
easily possible on this basis, which groups have a 
direct relationship with similar groupings that can 
be made on the basis of susceptibility to rheumatic 
group lesions. The local and systemic expressions 
are not only related, but are both symptoms of the 
same controlling forces and conditions. 



CHAPTER VI. 

ARE APICAL ABSORPTION AND TOOTH INFECTION 

SYNONYMOUS? 

PROBLEMS: Is it essentially true (a) that a tooth 
without risible absorption at its apex is not infected, and (b) 
that a tooth with risible absorption at its apex is infected? 

EXPERIMENTAL AND DISCUSSION. 

The entire system of dental diagnosis of today would seem to 
stand or fall on the correctness of these premises. This is true to 
so great an extent that the medical and dental professions of the 
country probably depend more on this one diagnostic means than 
all others combined. One has only to go to the ordinary diagnos- 
tic laboratory, whether that of a medical or dental roentgenol- 
ogist, and observe the procedure. The patients, whether they 
come in with or without a letter of reference, will be assigned to a 
technician for making a complete or partial set of dental roent- 
genograms of the mouth. The roentgenologist or one of his 
assistants takes the films one at a time and holds them between 
himself and the light, in the better equipped laboratories often, 
so arranged as to be very comfortable and convenient with a hole 
in the top of the table covered by a piece of opal glass and an 
electric light beneath. A form is filled out as film after film is 
handled, and a decision is made in an instant on the basis of the 
above presumption that a tooth without visible absorption at its 
apex is not infected and that a tooth with visible absorption at 
its apex is infected. 

Allowing ten films to each mouth, a little calculation readily 
suggests the amount of time that can be taken with each film. We 
know of several laboratories that claim to take complete sets of 
roentgenograms for fifty to one hundred patients a day, and have 
heard of laboratories reaching twice that maximum number. 
We would not suppose that even a skilled operator would under- 
take to interpret the films for more than one hundred patients 
per day. Assuming that the areas where teeth are absent are 
studied as well as the areas where teeth are present, which should 
be done, this operator would have to study the condition of 
several thousand teeth, or their sockets, a day. Assuming eight 

121 



122 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

hours continuous study of this very exacting problem and two 
thousand teeth to be studied, it would allow less than fifteen 
seconds per tooth. We are not here presuming to discuss whether 
the decision is or is not correct, but simply the fact that some 
fundamental law must prevail, and be very constant, to make it 
possible for these dental diagnosticians to decide the fate of so 
many hundreds of teeth per day on such few seconds of observa- 
tion of a record of their condition. There is no question but that 
this law is supposed to obtain: namely, that infection in a tooth 
will express itself as absorption at the root apex; and, conversely, 
that absorption at a root apex can have only one meaning: 
namely, dental infection. 

This research has been made to verify the correctness of these 
premises. Figure No. 51-A shows roentgenograms of the central 
and lateral incisors of a young man, none of which would appear 
from the Roentgen-ray shadows to be infected; nor would the 
shade of any of them suggest that they were infected or abnormal. 
The testing of each tooth individually for a temperature response 
revealed the fact that the upper left central gives no response. A 
careful examination of the tooth and tissue surrounding it re- 
vealed a small fistula opposite about the middle third on the 
labial surface of the root. The tooth was opened; and a smear 
stained and examined immediately was found to contain an 
abundance of very small diplococci. B and C show roentgeno- 
grams from different angles of the tooth with a flexible gutta-percha 
point placed in the fistula. E and F show two views, one a direct 
and the other lateral, of the extracted tooth with its granuloma 
in position on the side of the root, also revealing apical absorp- 
tion not revealed in the original roentgenograms. D shows a 
lateral roentgenogram of this tooth and discloses a very large 
lateral foramen which had its exit beneath the granuloma. A 
study of this tooth in Figure 51-A discloses a zone of condensing 
osteitis about the apex in the position which would usually be 
occupied by a zone of rarefying osteitis. In this chapter we are 
discussing the significance of what is apparent in the roentgeno- 
gram. It will readily be seen that a decision on the basis of what 
is apparent in the roentgenogram is utterly misleading in this 
case, for this patient had not only this serious local involvement 
but had also a systemic expression apparently influenced or 
caused by this involvement. Cultures were made under con- 
trolled conditions, all of which grew out long and short chained 
streptococci and diplococci in both aerobic and anaerobic condi- 
tions. 



CHAP. VI RELA HON OF \ [SIBLE ABSORPTION TO TOOTH INFE( riON 







Figure 51. Different views of an infected tooth where the roentgenographs 
evidence is negative. 

Had this lateral canal lain at right angles to the direction of the 
incidence of rays, the zone of rarefaction would have been on the 
side of the root instead of in front of or behind it, and would then 
probably have been disclosed. Such a case is shown in Figure 52. 

Figure No. 53 shows a series of four cases of the roentgenograms 
of similar central incisors that have been found to be definitely 
and seriously infected where little or no roentgenographic evi- 
dence is apparent. In the many hundreds of cases here being 
reported, in more than ten per cent of instances teeth were found 
by other methods of study to be infected where the Roentgen-ray 
completely failed to reveal or even suggest that condition. To 
illustrate the importance of this latter we will detail the serious- 
ness of these cases. 



124 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




Figure 52. A lateral abscess on the side of a bicuspid; also apical abscess. 
(See tooth with filling. i 




A. 445 



B. 581 




C 911 



D. 706 



F.gure 53. Four cases with putrescent central incisors. Condition not 
revealed roentgenographically. 



■ 



I 



I 



Figure 54. A mandibular cuspid with apical radiolucency below a vital 
tooth. 



CHAP. VI RE1 \l ION OF \ ISIB1 E VBSORP1 ION rOTOOTHINFE< HI >\ L25 

A shows a woman bedridden for main- months with heart and 
gall-bladder involvement, whose condition was so severe that her 
death was awaited hourly. She finally passed a large number of 
gall-stones alter which she greatly improved, and as soon as she 
could be moved was brought to us for study. One of the centrals 
shown in A is non-vital and the seriousness of its infection was 
demonstrated by animal inoculation with the culture. With the 
removal of this and a couple of other teeth showing also a very 
little evidence of infection, and whatever benefit she derived 
from the passage of the gall-stones (which, no doubt, was very 
considerable ) her condition has so greatly improved that for five 
years she has had no recurrence and is again doing her household 
duties with little or no evidence of heart involvement. 

B shows the roentgenograms of the teeth of a young married 
woman, age thirty-two, who was brought to us with a heart in- 
fection. This occurred some years ago when we had more courage 
based on ignorance, and we consented to treat and root-fill this 
tooth, and make a curettage of the root end. A couple of other 
teeth were extracted at this time. The patient's condition im- 
proved a great deal and she resumed the responsibilities of her 
home. During the overload of a subsequent pregnancy her heart 
became very badly involved again, at which time she was carried 
to us; and as she lay in the ward, had so much dyspnea that 
about every fifth breath she would gasp. Even while lying quiet- 
ly her pulse was 120. With the removal of this tooth, which 
(neither at the time of its first discovery and treatment or at this 
time, a couple of years after its root filling,) has never had any 
tenderness to suggest that there was anything wrong with it, the 
patient has had an apparently quite complete recovery, and has 
been taking care of her household duties, going up and down 
stairs, etc., for two years. She looks and feels splendid. In 
Chapter 60, on Circulatory System, I review this case with illus- 
trations of the heart lesions produced in rabbits by the inoculation 
of the culture from this root filled and curetted tooth. The im- 
portant item for us to stress is that so seriously an infected tooth 
gave no physical symptoms of being abnormal and, as in the last 
case, practically no roentgenographic evidence that it was not 
normal. 

C shows a case of very severe rheumatism which crippled the 
man so severely that he could walk only by shuffling his feet 





Figure 56. Showing zones of external anesthesia 
in the case of the previous figure. 



Figure 55. Maxillary anesthesia. 



■126 



CHAP. VI RE1 A lli >N oi-- \ ISIBLE ABSORPTION TO TOOTH INFE< HON 

slowly. His hands were equally helpless. With the removal of 
this infection his rheumatic symptoms, which had been recurring 
for some time, entirely and quickly disappeared and have not 
returned in four years. There was no change in the color of this 
tooth to suggest or indicate its condition and the patient vigor- 
ously protested against its removal though he is now extremely 
grateful. Figure 10. Chapter 1. illustrates the result of animal 
inoculation with this culture. 

Figure 53-D shows the roentgenograms of the central incisors of 
a young lady suffering from a very severe neuritis in her neck. 
She had had a serious fall and there was a fear at one time that 
her neck had been broken. This pain had persisted for months 
though with markedly changing severity. It is not known how 
much of the improvement that occurred in this case was due to 
the removal of dental infection but there seemed to be consider- 
able. 

These are just a few typical illustrations of the extreme need 
for more efficient methods of dental diagnosis, than the very 
questionable presumption that the extent of the dental infection 
is that which is suggested in the roentgenogram. As shown in 
these four cases there was practically no evidence, for in the last 
case (D) the tooth that was involved was one carrying a porce- 
lain filling, which looks like a cavity in the roentgenogram, and is 
not the one showing the two gold fillings and which does suggest 
the possibility of a periapical involvement. A close observation, 
however, of the involved tooth discloses a zone of condensing 
csteitis surrounding the apex of the upper right central. 

PROBLEM NO. 5B: Docs apparent absorption about 
a root apex necessarily reveal injection? 

Figure No. 54 shows a lower left cuspid with very definite evi- 
dence of absorption of bone about the apex of the root. By both 
the thermal and electrical tests, and by drilling of the dentin, the 
tooth responds with complete normality. This tooth would 
readily be condemned for root filling or extraction if complete 
dependence is to be made upon the evidence of the roentgeno- 
gram. 

Figure No. 55 shows the present condition of the upper incisors, 
each with areas of absorption, all of which according to history 
were getting larger. A careful study of the history, as furnished 
by the patient and the dentist, revealed the following: The 
woman was a colored servant in a home in another city. One day 



128 DENTAL INFECTIONS, ORAL AND'SYSTEMIC— RESEARCHES— VOL. I 




Figure 57 shows areas of arsenical necrosis on dog's tongue 
from devitalized teeth. 





Figure a8 shows several views of treated teeth, some with arsenic, others with 

FORMALIN. 




Figure 59. An enlarged apical medullary space resembling 
apical involvement. 



CHAP VI RE] n*ION OF VISIBLE ABSORPTION POTOOTHINFEt riON L29 

she observed that some of her teeth felt numb when she tapped 
them. She went to her dentist and he tested with thermal change 
and by drilling, and found that the central incisors had no sensa- 
tion and proceeded to remove the pulps which, as he described it 
to me afterwards, notwithstanding that the teeth were dead, bled 
like live pulps and that there was absolutely no life in them. He 
treated these teeth with tricresol-formalin and changed the medi- 
cine frequently. One after another, as he tested additional teeth, 
he found that they did not respond to temperature or to drilling, 
and he proceeded to remove the presumably lifeless pulps. These 
he also treated with tricresol-formalin and to his amazement, not- 
withstanding the fact that he changed the medicine very fre- 
quently, after weeks of continuous treatment he was not able to 
stop the apparent infection at the apices, for the abscesses, as he 
described them, grew larger and larger. A careful examination 
revealed that not only the teeth but the soft tissues of the entire 
upper jaw of this patient's mouth had no sensation. What had 
been taking place clearly was that teeth with normal pulps, but 
to which the nerve supply had been destroyed, had been removed, 
and sterile pulp chambers had been saturated with irritating 
medicament which penetrated the apices and produced an ever 
increasing zone of necrosis, and which areas were the result of irrita- 
tion of a kind other than bacterial . Figure 56 shows an outline of 
the zones of anaesthesia. In seven years there has been little 
change in the boundaries of the zones of anaesthesia, though it is 
becoming more complete. 

Figures 57 and 58 show the tongue and teeth of a dog, in whose 
teeth I placed arsenic and covered it carefully with amalgam 
fillings in cement to make a very tight seal. The dog was killed 
at the end of a week. The photograph shows large areas of 
necrosis on the tongue where the arsenic had penetrated from the 
pulp chamber (which is very small in dogs' teeth) through the 
root walls and apices to the supporting structures which were 
definitely necrosed and even produced extensive lesions on the 
dog's tongue as shown. 

There was a time in the history of the practice of dentistry, 
and not far removed, when many dentists — we hope none now 
were continually using arsenic for the devitalization of dental 
pulps; and I have frequency seen, when that practice was in 
vogue, areas of necrosis produced by the arsenic, which could 
easily be mistaken for zones of infection, and which could readily 




Figure 60. Mental foramina which might be mistaken for apical involvements. 




A. 1392 



F. 1393 



C. 1394 



Figure 61. Anatomical relationship of maxillary sinus 
and palate, suggesting apical involvement. 





Figure 63. Thickening of 
peridental membrane, due to 
orthodontia. 




Figure 62. Two views of nasopalatine foramina, easily 

MISTAKEN IN ONE VIEW FOR APICAL INVOLVEMENT. 



Figure 64. Putrescent 
bicuspid without apical 
involvement. 



130 



CHAP. VI RE1 \ lit >\ < >I \ [SIBLE ABSORPTION TO TOOTH INFECTION 131 

become focal on the entrance of bacteria. There can be no doubt 
that great damage lias been done by this practice. 

In Chapter 11 on Tooth Medications, I report our studies on 
the irritating effects of the medications currently used. Much 
work has been done since, demonstrating that dental medication 
may be a very definite cause of bone absorption about the apices 
of the treated teeth. 

\\ e very frequently see reports from non-dental diagnosticians, 
including roentgenographie interpretations of dental conditions, 
which specifically condemn and assign for extraction certain teeth 
which show evidence of apical absorption. Figure 59 shows a third 
molar with a zone of apparent decalcification which is in all prob- 
ability an anatomically large medullary space, for this tooth is by 
all physical tests normal. Figure 60 shows lower bicuspids in 
which the mental foramen has been mistaken for an apical ab- 
sorption. Figure 62 shows two centrals which have been con- 
demned because of the apparent apical involvement but are due 
to the angle at which they are taken, throwing the root apex in 
such a relationship to the nasopalatine foramen, that it appears as 
an apical absorption. Figure 61 shows three illustrations of an 
anatomical relationship as it is disclosed by the roentgenogram, 
and which appears like an abscess on the palatal root of the upper 
molars, and is produced by the transparent zone of the maxillary 
sinus in alignment with the anteroposterior grooves. 

Another type of irritation which can easily be misunderstood 
is that due to trauma, such as the overload in a tooth which fre- 
quently produces a very marked thickening of the peridental 
membrane, which, to the untrained, would readily be mistaken 
for a pericemental involvement. The removal of the overload, 
whether traumatic occlusion or the carrying of a fixed bridge, will 
usually entirely correct this condition. Another type of apical 
involvement also due to trauma of a different kind is produced in 
certain orthodontic procedures where, with the movement of the 
tooth, there is a distinct zone of rarefaction disclosed about it. 
Such a condition is shown in Figure 63. 

It is, of course, understood that much of the data in this chap- 
ter should be common knowledge and is inserted here for the 
benefit of those not familair with these facts. The need for it has 
been suggested by a very large number of interpretations that 
have come to my hands, which indicated that the diagnosticians 
making them were not familiar with these facts. 



132 DENTAL INFECTIONS. ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

It is common practice to depend upon the roentgenograms of 
teeth for a final decision as to whether they are or are not infected. 
I have previously stated that in our practice, approximately ten 
per cent of the teeth that we find to be infected and seriously in- 
juring the patients, do not have the same revealed by the roent- 
genograms. Figure 64 shows a bicuspid tooth with a putrescent 
pulp, which condition is not suggested by changes in the support- 
ing structures. In this patient's mouth several teeth were found 
similarly non-vital without any local symptom to suggest it. The 
patient was suffering from a nervous breakdown and her condi- 
tion greatly improved following the removal of the non-vital 
teeth. 

SUMMARY 

We are led by these studies to conclude : 

(1) That dental infection will not of necessity 
produce bone absorption at the apex of the root of 
the involved tooth; and 

(2) That absorptions, when they occur, are not of 
necessity a result of bacterial irritation. 



CHAPTER \ II. 
THE RELATION OF CARIES TO PULP INFECTIONS. 

PROBLEM: What is the relation of the health of pulps 
without exposure to shallow and deep caries? 

EXPERIMENTAL AND DISCUSSION. 

Dental literature and dental practice have taken for granted 
that teeth, with exposed pulps as a result of dental caries, may 
be and probably are infected; but that teeth, with a dental caries 
which has not reached and uncovered a pulp chamber, are not 
yet infected, and are available and safe for filling by the indi- 
cated procedures. Clinical experience, however, has indicated to 
all observing operators that teeth with large fillings tend to de- 
velop symptoms, more or less severe, of pulp involvement, very 
often observed as hypersensitiveness to thermal change, and 
later pulpitis and pericementitis. So many teeth were found 
having non-vital pulps in which there were no symptoms what- 
ever that the patient could distinguish that a series of careful 
studies was made to determine, if possible, the extent to which 
caries must have advanced before there was danger of pulp in- 
volvement, and what the early expressions in pulp tissue would 
be. 

A practice, still more or less common but more generally prac- 
ticed a few years ago, was that of pulp capping, by which some 
operators undertook to place over the zone of pulp involvement 
a non-irritating protection. Some of these were very ingeniously 
devised by making a little hood of gold or platinum into which 
was placed medicated paste, and the capping placed over the ex- 
posure and covered w r ith cement, over which the permanent filling 
was placed. Statistics indicated that this operation was more 
likely to succeed in hot climates than in cold. 

One of our experiences of years ago convinced us that there was 
danger in some of these pulp involvements to a degree far exceed- 
ing that which we had expected. A boy of fifteen years presented 
with a very acute rheumatism, being brought by a nurse from a 
Visiting Nurse Association. The history showed that four weeks 

133 



134 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

previously he was compelled to leave school because of an acute 
tooth-ache definitely located in the left mandible. This acute 
pain lasted only a few hours; then it entirely disappeared. About 
a week or ten days later it was found that he could not get up 
from his seat in school and had to be carried home with acute 
rheumatism which kept him in bed for two weeks, after which he 
was hustled back to school. The teacher reported that he did not 
seem to care to play with the other children and seemed very 
tired, which she and the visiting nurse interpreted as being due 
to the lingering rheumatism. To our amazement we found a very 
bad endocarditis, with the heart greatly enlarged and already 
some cyanosis. 

Examination of his mouth revealed deep caries without pulp 
exposure in the lower left first molar. The tooth was extracted 
and the boy ordered to bed under strict control of the district 
physician, which directions were not properly carried out; and 
he was buried in about seven months as a result of a complete 
breakdown of his heart. Before the tooth was extracted it was 
determined that the pulp responded nearly normally to irritation 
and thermal change. After extraction the tooth was sterilized 
externally, including the pulp cavity, and after the removal of the 
caries, culture was made from the pulp, which pulp, macroscopi- 
cally, was nearly normal except that it showed slight congestion. 
Of thirty rabbits inoculated from this culture, 93.3 per cent, (28) 
developed acute endocarditis within a few days, and 100 per cent 
developed acute rheumatism. This, with many other experiences, 
made us very suspicious of the pulps of teeth with deep caries and 
prompted these special studies. 

Teeth with more or less deep caries were accordingly selected 
for study. Figure 65 shows the pulp tissue underneath a caries 
that did not extend more than half way to the pulp but which was 
slightly abnormal to temperature change. The capillaries are 
enlarged and there is a marked infiltration of leucocytes just be- 
neath the odontoblastic layer, with an area of necrosis. This 
patient had symptoms of an acute neuritis, which, incidentally, 
were greatly relieved by the extraction of the tooth ; and it is very 
clear that a focal infection within the pulp is mechanically so 
situated that its toxic products must of necessity go into the 
lymphatic and hematogenous circulations; and, as necrosis pro- 
ceeds, organisms can readily enter each of these two circulations. 



CHAP. VII llll KM \l ion OF CARIES TO PI LP INFEC flONS 




Figure 65 shows the Peridental layer of the pulp immediately below a 
dental caries. see frontispiece for hemorrhage associated with pulpitis. 

In this case, as in many, the local symptom of pain and the re- 
actions in the sympathetic nervous system were entirely out of 
proportion to the direct toxic reactions. 

Figure 66 illustrates a very common type of pulp involvement 
following and accompanying deep caries. Figure 66- A shows a 
cross-section through the pulp of the three canals and the caries 
cavity on the mesial surface of an upper left second molar. It 
will be noted that the caries had extended only about half way to 
the pulp. Figure 66-B shows a roentgenogram of the tooth in the 
mouth with the metallic filling in place. In A is seen the location 
of a very large pulp stone, which type of calcification is expressing 
itself in many places as islands, as shown in Figure 66-D. There is 
a marked congestion of the blood vessels in the vicinity, which 
are shown in E. This was taken from the mouth of a man about 
sixty-five years of age, and his symptoms, as in the last case, were 
largely elsewhere; and it was only on testing that it was found 
that the pulp was abnormally sensitive to reactions from irritants. 
Figure 67 shows, similarly, extensive calcifications with multiple 
islands in a tooth with moderately deep caries but without pulp 
exposure. 





Figure 66. Pulp involvement and metallic filling: B, roentgenographic; 

A, CROSS SECTION OF CAVITY AND PULP; D, PULP STONES; AND E, HYPEREMIA AND FIBROSIS. 

136 



CHAP \ II THE RE1 \n<>\ 0F< VRI1 STOPULP INFE< I IONS L37 




Figure 67. Calcifications within pulp beneath moderate caries. 







Figure 68. Extensive calcification in pulp of tooth of a boy fourteen. 



138 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

It might be expected that a condition such as shown in Figure 66 
might be found in the pulps of teeth of individuals of an advanced 
age, independent of irritation. We have, accordingly, made 
studies of the pulps of young individuals to determine whether 
the condition is independent of the sclerotic changes attendant 
with advancing years. Figure 68 shows a calcification in the pulp 
of a molar tooth of a boy about fourteen, the tooth having deep 
caries of long standing. It will be noted that the island is very 
large and shows distinctly a lamellar laminar structure, indicat- 
ing that it was laid down in layers. It can readily be understood 
that, notwithstanding that this tooth had not yet given trouble, 
it would be very strange if it did not in the future. 

A bacterial examination of the pulps of teeth with caries has 
revealed that in practically all cases of pulp culture of deep caries 
without pulp exposure, the pulps were found to be infected; and 
in teeth with moderate caries not extending more than one-fourth 
the distance to the pulp, the pulps were found infected in approxi- 
mately 50 per cent of cases. It should not be implied that the 
presence of germs in the pulp would demonstrate that the pulp 
must later become a focus of infection, for it is definitely demon- 
strated that infections may involve the circulation temporarily 
as a result of acute colds and special epidemic infections. 

This condition of calcification may be located in islands or be 
adherent to a wall of the pulp chamber, or may surround the pulp 
tissue on all sides and almost entirely obliterate it. Figure 69 
shows two degrees of magnification of a section of the pulp 
through the root of a tooth where the calcification has reduced 
the lumen of the root to approximately one-eleventh of the orig- 
inal cross-section area. The dark area in the center is the pulp 
tissue; the granular layer is a calcified zone and is an osteoid 
structure. This tooth did not present local symptoms of abnor- 
mality, though the patient had very distressing symptoms of 
neuritis. Cultures from this tooth inoculated into animals de- 
veloped very marked disturbances and pathological changes. 

Some of these cases furnish the explanation for the so-called 
obscure neuralgias, the cause of which is ordinarily not found; 
and the patient may suffer both severely and long. Or it may be 
that the involved tooth may be located and proved to be one in 
which the dentist has placed a filling some months before; and 
the attitude of the patient will probably be one of very definite 
criticism of the judgment of the operator, assuming that he should 



CHAP VII II IK KM- 1 \ l 1 1 >\ OF CARIES TO PULP INFECTIONS 139 

ia\\\\ 












Figure 69. Tin-: pilling in of tiik pulp chamber with an osteoid bone. 

have known whether or not it was safe to place an expensive gold 
inlay over the pulp of the tooth, even though, up-to-date, it had 
not given trouble. Unless the operator knows the probability of 
this type of pathology, he will find it very difficult to make a 
defense or explanation that will be satisfactory to the patient; 
and until the patients know of this danger they will continue en- 
tirely to misjudge the operator. 

Figure No. 70 shows a case that illustrates this point. The 
patient has presented with an obscure neuralgia involving the 
left ear and the temple, with a symptom of hypersensitiveness to 
temperature change, which she locates in the upper teeth. No 
tooth is tender or has had a localized pain; yet the condition is 
severe. Careful examination reveals that the tooth that is ab- 
normally sensitive to temperature change is the lower left second 
molar. An inlay placed three months before is in excellent condi- 
tion. The history of the tooth is that the progressive caries had 
extended deeply, about half way through the dentin on both the 
occlusal and distal surfaces. On removal of the inlay, the dentin 
beneath a protecting layer of cement responded normally. It 
was decided that the pulp should be condemned and that this 



140 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




Figure 70. Pulp changes resulting from irritation of caries plus irritation 
of filling: C, original caries cavity in second molar; D. same with gold inlay; 
B, degeneration changes in pulp with fibrosis and calcification; and A, large 

PULP STONE IN CORONAL PORTION OF PULP, NOT DISCLOSED BY ROENTGEN-RAY. 



CHAP VII mi km \i ion 0F< \RIES TO PULP INFECTIONS Ml 

patient could have the roots of this tooth filled, provided good 
access could be had. The pulp was removed under mandibular 
anaesthesia and sectioned. The pulp is shown in Figure 70 to 
have very extensive zones of calcification. 

Other cases arc shown in Chapter 66 on "The Nervous System 
and the Sense Organs." 

Since the process of dental caries involves decalcification, the 
roentgenogram becomes a most important aid in detecting ob- 
scure zones and early stages of dental caries. This process of 
decalcification may be exhibited as extending from its beginning 
in the tooth to, or nearly to, the pulp. This is illustrated in 
Figure 71, in which a zone of decalcification is shown extending 
from a caries which has entered beneath an alloy filling and then 
has followed the dental tubuli directly toward the pulp. This is 
also shown clearly in Figure 72, in which the zone of decalcification 
can be traced in the roentgenogram from the open cavity directly 
toward the pulp. Figure B shows the pulp tissue directly be- 
neath this zone of decalcification, and Figure C islands of calci- 
fication within this pulp tissue. The process by which the decal- 
cification is carried on by bacteria and the systemic factors in- 
volved in it are discussed in Chapter 29 "Etiological Factors in 
Dental Caries." 

I desire to present in this chapter an illustration of the progress 
of dental caries pulpward through the dentin. Figure 73 shows 
the details of the base of the cavity of dental caries in two magni- 
fications revealing the etching of the tubuli and the advancement 
into these openings of the bacterial growth having entered the 



Figure 71. A zone of decalcifi- 
cation EXTENDING FROM THE CARIES 
CAVITY TOWARD THE I'ULP. 

(See second molar 



tubuli. The direction of this can most readily be made toward 
the pulp. The organisms furnish their own tools for dissolving 
the dentin, and progress as fast as they have enlarged the tubuli. 
B shows the enlargement of the tubuli far below the surface caries. 
The toxic substances produced by these organisms have as direct 





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142 



un\i'. \ n nil-: RELATION OF< \un> fOPl LP i\i i i i n»\s I 13 




Figure 73. An illustration of the depth of decalcification from a superficial 
caries: b. from the base of the caries cavity inward, showing the enlarged 
dental tubuli; a. enlargement of the dental tubuli, showing bacterial advance- 
ment far toward the pulp. 



access to the pulp as to the open cavity, and will most naturally 
develop in that direction, because it is in the direction of their 
food, since they live on the disintegrating tissue material which 
their own toxins devitalize in their advance. 



144 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES- VOL. I 



/ 






FIGURE 74 SHOWS PROGRESSIVE DEVELOPMENT OF INFECTION TOWARD THE PULP 
FROM CARIES CAVITY UNDER INCREASING ENLARGEMENTS IN A, B, AND C. 



CH \l' \ II l WE REJ \ riON < IF C tRIES IX) PI LP 1M Ia i i< i\s I I.". 

In Figure 74-A we have a cross section of the molar shown in 
the roentgenogram in 71-1). In the latter you will note a large 
alloy filling in the occlusal surface of the molar, and a distal cavity 

of caries at the point of contact with the malposed third molar. 
This tooth was vital and producing sympathetic disturbances 
from pulpitis. In B we have a magnification of the zone included 
in the oblong outlined in the margin of the caries cavity of A, but 
enlarged about 200 diameters; and in C we have a zone from the 
base of this area of the cavity, which is outlined in the oblong in 
B, enlarged to about 1200 diameters. In this latter the dentinal 
tubuli are shown enlarged to a point where the etching out of 
their lumina can be distinctly seen. The irritation upon the pulp 
tissue has been in progress for a long time, with the result that 
there has been a progressive degeneration, first as a congestion, 
then a fibrosis and calcification, the latter of which is shown in A 
at the point of fusion of the mesial and distal canals. This zone 
is shown enlarged in Figure 75-A ; and it will be noted that in ad- 
dition to the large islands that were so clearly seen and outlined 
in Figure 74-A, there are myriads of small ones resulting from the 
fibrosis. In Figure 75-B, a zone of the dentin beneath and at the 
margin of the leaking alloy filling is shown enlarged to about a 
thousand diameters; and in C, enlarged to about 1800 diameters. 
It would not be difficult to find arguments for and against 
the conclusion that the bodies shown are microorganisms. We 
will not introduce a discussion of this phase of the problem in this 
chapter. Whether these are organisms or products resulting 
from bacteria] growth, the resultant irritation upon the pulp 
tissue has been very positive. 

t But these inflammatory irritations are not limited to the pulp 
itself, but are extended to the peridental membrane and the 
supporting structures. This is shown in Figure 76, A and B. In 
A we have marked changes in the vascularization. The large, 
dark, round area is a calcification within the lumen of a blood 
vessel. Between it and the cementum another blood vessel is 
shown in the process of degeneration. Transverse fibers are in- 
vaded with round cells and leucocytes, with much evidence of 
inflammatory process. These irritation processes produce at 
some points degeneration with absorption, and at others, prolif- 




■■■•■•. ..'• ■ w , ■•;■'•;■.- . 



" -■■ . ■''... 






• ! ^T f: : '"•• 



• 






"w 






FlGURE 75 SHOWS CALCIFICATION ZONES IN PULP IN A; THE DENTIN BENEATH A LEAKING AI I nv 
FILLING IN B; HIGH POWER OF SAME IN C. ALLOY 

146 



CHAP. VII fHE RELATION OF CARIES TO PULP INFE< flONS 147 




Figure 76. Structural changes in the peridental membrane and cementum of tooth shown in Figures 
74 AND 75. A shows calcification in a blood vessel, B, absorption of cementum and replacememt with 

AN OSTEOID TISSUE. 



148 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




Figure 77 shows a zone of degenerating osteoblasts beneath a zone of caries. 



eration with hyperplasia, as shown in B, in which an absorption 
cavity in the cementum has been later built in with osteoid struc- 
ture ; and these structures will always remain as scar tissues and 
with less than a normal defense against infection. 

In Figure 77 we have a zone of the odontoblastic layer of the 
pulp just beneath a zone of caries. The toxic substances from the 
bacterial growth are penetrating into the pulp tissue. The odon- 
toblasts in this zone have been devitalized. Their nuclei ceased 
to stain. Connective tissue is proliferating abundantly; and 
whether infection has already invaded the pulp or not, the scar 
tissue has been formed, which will probably express itself as a 
calcification and remain as a permanent injury to the function 
of the pulp. 



ell AT \ II THE RE1 \ HON OF C KRIES rO PI LP INFE< I 1' >NS 



1 I'.i 




Figure 78. Bacterial invasion and necrosis in dental pulp beneath caries. 



The bacteria] invasion of the pulp usually progresses through 
the various stages of inflammation, first with congestion as part 
of the heroic reaction of the tissues to stamp out the invasion, 
then the paralyzing of the tissues and their degenerative forces 
with the resultant degeneration with the subsequent necrosis. 
At some stages of an acute pulpitis, bacterial invasion can be dis- 
closed in the vital pulp. Such a case is shown in Figure 78, shown 
here stained with Giemsa stain. In this case there is marked 
degeneration of the odontoblastic layer, with fibrosis. 

SUMMARY AND CONCLUSIONS. 

This research has included the sectioning, culturing, and animal 
experimentation on many teeth with deep caries which were 
found to have abnormal reactions though nothing was disclosed 
by the roentgenograms ; and has demonstrated to us that 
Teeth with deep caries generally, and moderate 
caries frequently, already have their pulps involved 
from that source and cannot be dismissed as normal 
without further study by means other than the 
Roentgen-ray. 



CHAPTER VIII. 

THE RELATION OF PERIODONTOCLASIA TO PULP 

INFECTIONS. 

PROBLEM: Are the pulps of teeth influenced or injured 
by periodontoclasia {pyorrhea alveolaris) unless and until 
that pathological process has mechanically severed or in- 
vaded the vessels entering the tooth at the root apex? 

EXPERIMENTAL AND DISCUSSION. 

Dental practice and dental literature have recognized in the 
inflammations of the supporting structures of the teeth a direct 
danger of systemic involvement from the pathological processes 
about the tooth, but have taken for granted that the pulps are 
not in general involved except in very far advanced stages of this 
disease. These studies have accordingly been made to establish 
the earliest expressions of pulp involvement resulting from per- 
iodontal inflammation and infection. This particular chapter 
does not include the etiology of periodontoclasia. It has to do 
only with its effects on pulp tissue. Our interpretation of the 
etiology of this condition will be found in Chapter 28. 

The earlier conceptions of this disease considered it as well nigh 
incurable, an opinion which does not generally obtain today. The 
newer conception regarding its amenability to treatment, how- 
ever, has not recognized that even though the tissues about the 
tooth are put in relatively normal and safe condition, changes 
may have occurred in the pulp before that treatment was estab- 
lished, which may permanently jeopardize the pulp. Figure 79 
illustrates such a case. In this case chronic periodontoclasia 
(pyorrhea alveolaris) had existed for years. The teeth were put 
under modern and efficient treatment ; the disease was supposedly 
arrested ; and the teeth became quite solid and comfortable. The 
old infection had, however, produced very extensive changes in 
the pulp tissues of these teeth. The pulp of this root had been 
divided by calcification which had extended across the entire 
pulp chamber. Very many pulp stones had formed. One is 
shown nearly half obliterating the remaining lumen. This tooth 
was still responsive to thermal change but was producing system- 
ic disturbances. B, the insert, shows the roentgenogram of the 
tooth. 

150 



CHAP. VIII RE] mONOFPERIODON TOCL ASI A TO PU1 PINFEC flONS !•>! 



YTTT-i 




FIGURE 79. A DEGENERATING PULP, DUE TO PERIODONTOCLASIA. A, MULTIPLE PULP STONES, FIBROSIS; 
GRAPHIC APPEARANCE. 

The irritation from periodontoclasia may produce calcifica- 
tions within the pulp chamber in a number of different forms. 
Whereas the tendency is quite largely to the formation of islands, 
it not infrequently occurs that a fibrositis develops within the 
pulp tissue, which later becomes calcified. We cannot conceive 
of a pulp's retaining its capacity for normal functioning, when such 
conditions develop, for it is embarrassed both by the osteoid 
structure within it which lowers the vitality of the pulp tissue, 
and by the abundant infection present in the vicinity which is 
available for infecting very quickly any pulp tissue in which the 
defense has become lowered. Such a case is shown in Figure 80. 
In this it will be seen that the pulp at the apex where it was sub- 
jected to the direct irritation of the toxic products is almost solid- 
ly calcified. Some nutrient vessels passing between these fibers 
maintain the vitality of the coronal portion of the pulp. These 
teeth have an entirely different relationship to the patient and 
his health in the early stages, when his defense is high and before 
the resistance of the pulp has been lowered, and it has beenin- 



B, ROENTGENO- 



152 DENTAL INFECTIONS, ORAL AND SYSTEMIC-RESEARCHES— VOL. I 




Figure 80. A fibrositis of the pulp, followed by calcification of same. 



volved, from the condition which exists in the patient with low- 
ered defense and with this serious pulpal disease. From the 
patient's standpoint, and perhaps from most operators' stand- 
points, the tooth in the latter condition might be considered less 
serious because it is less loose than it had been previously. It 
may, however, have taken on a condition in which, with the 
patient's lowered defense, it may seriously jeopardize his health, or 
start a degenerative process in some organ or tissue of the body. 
This phase will, however, be discussed in later chapters. 

I started investigations on this problem in 1916 while directing 
the activities of The Research Institute of the National Dental 
Association, which were carried out and reported by Dr. Kather- 
ine R. Collins/ which report was given before The National 
Dental Association in Chicago in 1917, and published in the 

2 See bibliography. 



CHAP. VII] KM tTIONOFPERIODON IXJCLASI A TO PULP INFECTIONS 153 

Journal of the National Dental Association, VI, L919, L64-170 
(Information to Date on Infections within the Root and Periap- 
ical Tissues; ami pages 370-373 of the same journal (Preliminary 
Report on Bacteria Found in Apical Tissues and Pulps of Ex- 
tracted Teeth). 

Following this work some special studies were made by Drs. 
Hartzell' and Henrici, 3 University of Minnesota, and reported in 
the Research Jul., 1. 1919, 419-422 (The Bacteriology of Vital 
Pulps). 

SUMMARY AND CONCLUSIONS. 

From these few selected illustrations of a general pathological 
reaction, it is evident to us that there may be a pulp irritation 
resulting from periodontoclasia long before a pocket has ad- 
vanced to the vicinity of the apical third of the root. This irri- 
tation may express itself in very marked structural changes which 
may often be of a nature (because of calcifications), which will 
permanently destroy the normal functioning of the pulp. That 
such pulps can become the source of a focal infection involving 
the entire system has been abundantly demonstrated and is 
discussed in succeeding chapters, as is also the pathology of the 
changes which occur in pulp tissue, cemental tissue, and dentin. 
The evidence at hand suggests to us that 

Deep pockets of periodontoclasia generally, and 
shallow pockets of periodontoclasia frequently, have 
already injured the pulp of the tooth, which tooth 
may be potentially much reduced in its safety from 
normal though it may have very great value and 
efficiency for mastication, and being potentially a 
danger must be continually watched. 

3 See bibliography. 



CHAPTER IX. 

THE RELATION OF DENTAL CARIES TO SYSTEMIC 

DISTURBANCE. 

PROBLEM: Is there a relationship between suscepti- 
bility to dental caries and to systemic involvements of the 
rheumatic group lesions? 

EXPERIMENTAL AND DISCUSSION. 

We do not find in the literature or the fundamental thought of 
dental practice a clearly expressed conviction indicating the ex- 
istence of a relationship between susceptibility to dental caries, 
and susceptibility to systemic involvements, and this study has 
been made to determine, if possible, whether there be any such 
relationship. We have carefully tabulated the presence of dental 
caries as a dominant factor in the life, or at some period during 
the life, of each of the cases here reported, inasmuch as that part 
of a tooth, that is once lost by decay, is always lost, for even 
though the tooth is filled, the mark of that ravage has been writ- 
ten in a form that cannot be obliterated. If the teeth are absent, 
true they may have been lost because of periodontoclasia. If, 
however, the teeth are present, showing very extensive fillings or 
open cavities, or absent, with no evidences of periodontal disease, 
it can be quite accurately determined that caries has been con- 
spicuously dominant in the mouth being studied. 

By dividing the patients into groups ranging from absence of 
systemic affection through mild to severe, and noting the propor- 
tion of dental caries in the mouths of these various groups, we are 
able to study relationships between these two types of disturb- 
ances. In Figure 81, we have in the first column the names of the 
groups in terms of their susceptibility to systemic involvement: 
namely, absent, acquired, inherited one side mild, inherited two 
sides mild, inherited one side strong, and inherited two sides 
strong; in Column two, the number of severe rheumatic group 
lesions in fifteen patients and their families; in Column three, the 
number of severe and mild rheumatic group lesions in fifteen 
patients and their families; and in Column four, the percentage 
of the group of fifteen individuals having extensive caries. From 

154 



CHAP. IX RELATION OF DENTAL CARIES fOSYSTEMIC IMMI RBAN( I L55 



Relation »>t Carats to Susceptibility u> Rheumatic Group Lesion 
Fifteen rypical Families in each Group. 


Susceptibility 


No ol 1 esions p ■[ K. mul\ 


Pa cent with 

l U 

40 

SO 

hi 
so 
v.< 


Sovoro 


Severe and mild 


Absent 

Acquired 

Inherited 

i side mild 
Inherited 

1 side strong 
inherited 

2 sidos mild 
Inherited 

2 sides si 


16 
HI 
258 
227 
183 


31 
96 

201 

338 

308 
754 



Figure 81. 

this chart it will be seen that in the first, the absent group, the 
percentage of individuals with caries, including mild and severe, 
is 40; in the second, the acquired group, 80; inherited one side 
mild, 67; inherited one side strong, 80; inherited two sides mild, 
93; and inherited two sides strong, 93. 

Even more striking is the parallelism between caries and the 
tendency to rheumatic group lesions, as shown in Columns two 
and three. In Column two, the total number of severe rheu- 
matic group lesions found in the individuals and their families, 
with an absent susceptibility, is 16; acquired susceptibility, 63; 
inherited susceptibility, one side mild, 144; inherited, one side 
strong, 258; inherited, two sides mild, 227; inherited, two sides 
strong, 483. In Column three, the combined severe and mild 
rheumatic group lesions, respectively, are 31, 96, 201, 338, 308, 
and 754. 



Relation of Caries to Susceptibility in 681 Individuals 



Absent 
Susceptibility 



Acquired 
Susceptibility 

130 



Inherited 
Susceptibility 

327 



Figure 82. 

In Figure 82 we have divided all cases of caries into three funda- 
mental groups of individuals: namely, absent, acquired, and 
inherited; and we find that in 681 individuals, 73 were classified 
as having absent susceptibility and caries, 130 acquired suscep- 
tibility and caries, and 327 inherited susceptibility and caries. 
The reader must distinguish that these are not ratios expressing 
caries in terms of susceptibility, but the number of individuals 



156 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 



in the various groups who have caries. These studies show clearly 
that there is a very marked increase in susceptibility to caries 
with increased susceptibility to rheumatic group lesions whether 
or not either is causative to the other. 

We have, accordingly, made an analysis of the different types 
of susceptibility for the purpose of determining whether or not 
caries bears a higher percentage of dominance in individuals with 



Relation of Caries to Type of Rheumatic Group 


Lesions 






Per cent 


Digestive Tract 


70 


Internal Organs 


70 


Nerves 


90 


Rheumatism 


90 


Heart 


100 


Kidney 


100 



Figure 83. 

marked susceptibility to the various types of rheumatic group 
lesions. In Figure 83, we have related caries to each of the follow- 
ing: a susceptibility to digestive tract, internal organs, nerves, 
rheumatism, heart, and kidney; and it will be seen that these 
severe affections have been found in our groups to be associated 
with caries in ratios running from 70 to 100 as follows : Digestive 
tract, 70; Internal organs, 70; Nerves, 90; Rheumatism, 90; 
Heart, 100; Kidney, 100. 

RELATION OF CARIES TO SYSTEMIC SUSCEPTIBILITY 



Inheritance Group 


No. of 
Families 
in Group 


Percentage of 

Individuals 

with Extensive 

Caries 


1 Dental Patients with No Developed Susceptibility 

2 Dental Patients with an Apparently Acquired 
Susceptibility 

3 Dental Patients with a Susceptibility and with 
one or both Parents acting as Carriers Only 

4 Dental Patients with a Susceptibility and with 
only One Side of Ancestry, including the Parent 
Involved 

5 Dental Patients with a Susceptibility and with 
Both Sides of Ancestry, including Both Parents 
Involved 


35 

12 
27 

16 
8 

7 


51% 

91% 

78% 

81% 

88% 

100% 



Figure 84. 



CHAP. IX RELATION OF DENTA1 ( VRIES TO SYSTEMIC DISTURBANCE 157 

In Figure 84, we have made a classification on the basis of sus- 
ceptibility both where the parents acted as carriers only and 

where they were themselves involved from one or both sides of 
the ancestry, and have figures, as will be seen, ranging from 51 
per cent m the absent group to 100 per cent in the inherited, both 
sides strong with both parents involved. This chart was made 
in 1919 and agrees in general with the recent findings of V.Y2'2, 
shown in Charts 81, 82, and 83. Itshowsdental patients with absent 
susceptibility, percentage of individuals with extensive caries, 51 ; 
acquired susceptibility. 91; another group of the same classifica- 
tion, 78; inherited susceptibility, one or both parents acting as 
carriers only, 81 ; inherited susceptibility, with one side of ances- 
try, including that parent involved, 88; with both sides of ances- 
try, including both parents, 100. 

SUMMARY AND CONCLUSIONS. 

From these data we feel compelled to conclude that one of these 
three conditions must prevail: First, that rheumatic group le- 
sions are causative in the production of caries; or second, that 
dental caries is directly causative in the production of rheumatic 
group lesions; or third, that both are symptoms of a systemic con- 
dition. This will be discussed later. 

We would accordingly change our previously accepted funda- 
mental which concluded that there is no relationship between 
caries and systemic involvements to the following: 

Susceptibilities to dental caries and to rheumatic 
group lesions are proportional, whether as cause and 
effect or as related symptoms. 



CHAPTER X. 

THE RELATION OF PERIODONTOCLASIA TO 
SYSTEMIC DISTURBANCE. 

PROBLEM: Is there a relationship between susceptibility 
to periodontoclasia (pyorrhea alveolaris) and susceptibility 
to systemic involvements of the rheumatic group lesions; or 
stated differently, is it not true that with an increase of suscep- 
tibility to periodontoclasia there is a marked increase in sus- 
tibility to rheumatic group lesions? 

EXPERIMENTAL AND DISCUSSION. 

In undertaking the study of this problem, as herewith outlined, 
we seem to be wasting time with a fundamental that is so generally 
accepted that it must of necessity be correct. Surely with the 
increase in prejudice of various affections, from a relative indiffer- 
ence to dental decay and some apprehension for apical involve- 
ments and putrescent pulps, we come by progression, in the 
thought of the laity, and we think of the professions, in so-called 
periodontoclasia to the most dreaded of dental lesions. Many of 
the laity are as alarmed over the thought of periodontoclasia's 
having attacked their mouths, as they would be over some terri- 
ble affliction like leprosy. Such a firm conviction, it would seem, 
can only be born in fact. Probably few, if any, headlines in the 
advertisements of current literature will be so largely read as the 
advertisements for cures for periodontoclasia. We have, accord- 
ingly, taken up the study of this scourge with an expectation 
amounting to a confidence that our data will show conclusively 
that an increase in susceptibility and dominance of this affection 
will be continually accompanied by an increase in severity and 
susceptibility to the rheumatic group lesions. 

In our careful analysis of these 681 cases, we have found 579 
have had rheumatic group lesions, and only 102 were without 
rheumatic group lesions; and of the 681, 508 have extensive caries 
and only 155 periodontoclasia. 

158 



CHAP \ RE1 \i ION PERIODON TOCLASIA TO SYSTEMIC DISTURBANC1 159 



Relation ol Periodontoclasia to Susceptibility i<> Rheumatic Group Lesions 
Fifteen typical families in each group Group Tun. 


Susceptibility 


No. of lesions \xr i unily 


l',t cenl ' " "'"' 
c "" s tod.isia 


ere 


Severe and mild 


\ sent 
Acquired 

Inherited 
l side mild 

Inherited 

'J aides mild 
Inherited 

1 side Btro 

Inherited 

2 sides so 


hi 
63 

lit 

227 
258 
483 


31 
96 

201 

308 
338 
754 


10 

80 
67 

93 

80 
93 


40 
33 

33 

20 

20 





Figure 85. 

In Figure 85, we have related periodontoclasia to systemic in- 
volvements in association with dental caries as presented in 
Figure 81 of the previous chapter, No. 9. These data show in 
the last column, Group 1, that the percentage with periodonto- 
clasia was 40, corresponding to the percentage with severe and 
mild caries; in Group 2, acquired, periodontoclasia 33%, caries 
80 r < ; Group 3, inherited one side mild, periodontoclasia 33 r ( , 
caries 67 r r ; Group 4, inherited two sides mild, periodontoclasia 
20 r o caries 93 r t ; Group 5, inherited one side strong, perio- 
dontoclasia 20%, caries 80 r ( ; and in Group 6, inherited two sides 
strong, periodontoclasia 0%, and caries 93 r ; ; and in the entire 
681 cases, periodontoclasia 23 c " ( and caries 75%. Columns 
three and four show respectively the total number of severe, 
and severe and mild lesions of the groups consisting of 
fifteen individuals and their families. 

In Figure 86, in the chart made in 1919, Group 1, Patients with 
no developed susceptibility, severe periodontoclasia 23 f 7 . exten- 
sive caries 51 r f ; Group 2, Acquired susceptibility, periodonto- 
clasia 33^, dental caries 91 c { ; Group 3, Inherited susceptibility 
with one or both parents acting as carriers only, periodontoclasia 
25^7, caries 81 r ( ; Group 4, Inherited susceptibility strong on one 
side of ancestry, including that parent, periodontoclasia 0, 
extensive caries 889c ; Group 5, Inherited susceptibility with 
inheritance strong on both sides, including both parents, perio- 
dontoclasia 0, extensive caries 100 r f . By referring back to Figure 
44, Chapter 4, the relationship of these figures to the increasing 
dominance of rheumatic group lesions will be readily seen. 

Analysis of the 681 cases shows that in that number 167 had 
periodontoclasia, distributed in the three groups — absent, ac- 



160 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 



RELATION OF PERIODONTOCLASIA TO SYSTEMIC SUSCEPTIBILITY 

Group One 



Group 


No. of 
Families 
in Group 


Percentage of 

Individuals 

with: 


Extensive Periodon- 
Caries toclasia 


1 Dental Patients with No Developed Suscep- 
tibility 

2 Dental Patients with an Apparently Acquired 
Susceptibility 

3 Dental Patients with a Susceptibility and with 
one or both Parents acting as Carriers Only 

4 Dental Patients with a Susceptibility and with 
only One Side of Ancestry, including the Parent 
Involved 

5 Dental Patients with a Susceptibility and with 
Both Sides of Ancestry, including Both Parents 
Involved 

* Two groups. 


35 

*12 

*27 

16 
8 

7 


51% 23% 

91% 33% 
78* j 26% 

81% 25', 
88% 
100% 



Figure 86. 
RELATION OF PERIODONTOCLASIA TO SYSTEMIC SUSCEPTIBILITY 





Susceptibility 


Absent 


Acquired 


Inherited 


Total No. of Patients 

No. of Patients having Periodonto- 
clasia 

Percentage of Patients having Per- 
iodontoclasia 


102 
49 
48 


174 
51 
29 


405 
67 
16 



Figure 87. 

quired, and inherited — in the following percentages: Absent 
susceptibility, 48%; acquired susceptibility, 29%; and inherited 
susceptibility 16%. (Figure 87.) 

In Figure 88, we have made groupings in accordance with the 
type of lesion as we did in the previous chapter on caries. Diges- 
tive tract, periodontoclasia 20%, caries 70%; Internal organs, 
periodontoclasia 30%, caries 70%; Nerves, periodontoclasia 30%, 
caries 90%; Rheumatism, periodontoclasia 10%, caries 90%; 
Heart in patient and family, periodontoclasia 10%, caries 100%; 
Kidney, periodontoclasia 10%, caries 100%; Rheumatism and 
heart, periodontoclasia 0, caries 100%. 



Relation ol Periodontoclasia t>> l\|»- 


.ii Rheumatii 




Group Lesions 






r 

Canes 


i 

iodonto 
clasia 


1 digestive Trad 


70 


20 


Internal Organs 




30 


Nerves 


90 


30 


Rheumatism 


90 


10 


Heart 


LOO 


id 


Kidnej 


LOO 


in 



Figure 88. 



In Figure 89, we have arranged a group of typical illustrations 
of gingival affections. In these, we have selected, as nearly as 
possible, the same irritant in the different classes of cases (and 
that a well known and all too common cause) namely, the im- 
pinging and irritating edge of bad fillings and open contacts pro- 
ducing food packs. In A, we see very extensive absorption of 
alveolar bone; in B, much less marked; in C, a slight area of ab- 
sorption surrounded by an area of condensed bone; in D, practi- 
cally no absorption of alveolar bone and a marked zone of con- 
densed bone. When we relate these to susceptibility to the rheu- 
matic group lesions, we find that A tends to be typical of those in 
the absent group; B and C, those in the acquired or mildly in- 
herited groups; and D, those in the strongly inherited and strongly 
involved group. A survey of the illustrations that are used 
throughout the various studies, as in all the preceding chapters, 
will show how generally these conditions obtain. 




Figure 89. Food packs and gingival irritants, with different types of reaction. 

161 



162 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

In general, it is not true that, with an increase of susceptibility 
to periodontoclasia, there is an increase in susceptibility to the 
rheumatic group lesions; but on the contrary, those with no sus- 
ceptibility to rheumatic group lesions, whether inherited or ac- 
quired, have a larger percentage of periodontoclasia (pyorrhea 
alveolaris) than any of the groups, ranging from mild to severe, 
of susceptibility to rheumatic group lesions. Our interpretation 
of these new and important phenomena will be given in the de- 
velopment of this general interpretation, in their places in sub- 
sequent chapters. 

SUMMARY AND CONCLUSIONS. 

From these data, we find an apparent contradiction to the 
thought and teaching of dental and medical science that is noth- 
ing short of bewildering. We have gone over our figures time 
after time to see if we have not made a mistake, but do not find 
such. Figure 86 made in 1919, and Figures 85 and 87 made 
recently, 1922, were made by different individuals. Those making 
the last charts not only did not know the figures of the previous 
study, but did not know that such a comparison had ever been 
worked out. 

We are, apparently, dealing here with fundamental new truths 
which will have a great bearing on the explanation of the con- 
fusion which has been so dominant throughout the entire history 
of dental and medical science ; and no conundrum has more com- 
pletely and continually baffled solution than has the etiology of 
periodontoclasia, or so-called pyorrhea alveolaris. We would, 
accordingly, re-state the accepted fundamental, that with an 
increase of susceptibility to periodontoclasia, there is a marked 
increase in susceptibility to rheumatic group lesions to the follow- 
ing: 

Individuals with marked susceptibility to periodon- 
toclasia have, as a group, a decreased susceptibility 
to the rheumatic group lesions during the period of 
its active development (In its secondary stages it 
may contribute to rheumatic group lesions) ; or ex- 
pressed otherwise, individuals with a very marked 
susceptibility to rheumatic group lesions tend, in 
general, to be free from extensive periodontoclasia; 
and when rheumatic susceptibility does develop, it 
would generally be classed as an acquired factor. 



I IIAITKR XI. 

RKLATK )NSHIPS 1 BETWEEN PERK )I )( )NT( X/LASIA 
PYORRHEA ALVEOLARIS) AND THE EXTENT OF 

PERIAPICAL ABSORPTIONS. 

PROBLEM: Is there a relationship between the root 
Old expression of irritation and the gingival expression of 
irritation; or otherwise expressed, is there in a given case 
no relationship between the size of apical abscesses from 
infected roots and extent of periodontoclasia^ 

EXPERIMENTAL AND DISCUSSION. 

We do not find in the literature or the opinions of dental prac- 
tice, evidence other than would tend to demonstrate or verify that 
there is no connection between the extent of the absorption, in 
case of apical abscess, and the extent and type of gingival absorp- 
tion, as occurs in so-called pyorrhea alveolaris. These studies 
have been made to determine whether or not there be any such 
relationship. 

In Figure 90, we have in the teeth of the upper arch (upper right 
first molar, upper left biscuspids and first molar) evidences of ex- 
tensive periodontoclasia. The supporting alveolus has been very 
extensively destroyed, the gingival crest completely obliterated, 
and the lamina dura disintegrated to, or nearly to, the apices of 
the roots. In the lower arch will be seen a lower incisor and a 
cuspid root, each with periapical involvement, not of moderate 
degree but of great extent. This patient is fifty-two years of age, 
has never had any of the rheumatic group lesions, and not only 
has excellent health but carries an enormous overload of care and 
work all the time with apparent ease. 

In Figure 91 we have a case with a marked tendency to periodon- 
toclasia that has existed for many years but has passed from the 
active to the chronic stage. The patient is suffering at this time 
from an abscess in her scalp which she said seemed like a boil, 
though it has persisted in discharging for many weeks. She is 
fifty-seven years of age and has carried all this infection without 
injury until recently, when the above trouble developed, and 
also eye trouble. The upper left first bicuspid shows distinctly a 

163 



164 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 





CHAP. XI RELATION OF GINGIVA! IX) PERIAPICAL ABSORPTION L65 

zone of condensing osteitis abmu the rarefying from one view. 
This is also shown mildly about the extensive apical infections 
of the molars. This patient has reached the time when she can 
no longer defend herself against this infection. This patient has 

had, as will be soon, evidence of very extensive absorption about 
the molar roots. She has born entirely free from all rheumatic 
group lesions during her entire lifetime, until the beginning of the 
recent disturbances. These, incidentally, appeared simultane- 
ously with a very severe overload occasioned by the illness and 
death of her sister, whose fatal illness had been caused by a septi- 
cemia resulting from a dental infection which had remained in a 
chronic condition for many years, but which, when her resistance 
wont down at seventy-two years of age proved fatal after an ill- 
ness of about six weeks. 

In Figure 33, we have again much cause for irritation and prac- 
tically no absorption of alveolar bone, no apparent tendency to 
periodontoclasia, and again pulp chambers with much cause for 
irritation and exceedingly little disturbance about the root ends. 

When we relate these to the patient's susceptibility to rheu- 
matic group lesions, we find in Case 1, practically no susceptibil- 
ity and very marked periodontoclasia and extensive periapical 
absorption; in Case 2, mild periodontoclasia and apical absorp- 
tion, and mild susceptibility to rheumatic group lesions, a condi- 
tion frequently seen in acquired susceptibility; and in Case 3, no 
tendency to periodontoclasia and slight periapical absorption, 
and a strong tendency to rheumatic group lesions. 

These three selected illustrations are not presented as being 
sufficient for final conclusions, but simply as typical illustrations; 
and an analysis of the illustrations of any of the chapters will 
show the same general principle. It must be kept in mind, how- 
ever, that in order to make a comparison of reactions we must 
know that both the gingival and apical irritants were operating 
at the same period in the patient's life ; otherwise, there may be an 
apparent contradiction, as, for example, if periodontoclasia were 
progressive during a period of high resistance, which for any 
cause was reduced so that the same irritations did not produce a 
continued progression of the absorption process, a condition of 
acquired susceptibility to rheumatic group lesions may develop, 
during which the defense is definitely lowered and consequently 
the reaction much less acute, in which state, caries may develop 
with pulp involvement, and with the characteristic apical reaction 



166 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

of an individual, without susceptibility to periodontoclasia, sig- 
nifying simply a diminished or lost capacity for normal reaction. 

SUMMARY AND CONCLUSIONS. 

There is apparently a very definite relationship between these 
various affections and reactions, which we have discussed in later 
chapters; and we would, accordingly, restate the premise as fol- 
lows: 

There is a direct relationship between tendency 
to absorption of alveolar bone in response to irri- 
tation, whether at the gingival border or at the 
root apex; and individuals with extensive peri- 
odontoclasia have much more extensive areas of 
absorption at the apices of infected roots than do 
patients without a tendency to periodontoclasia. 



CHAPTER XII. 

THE RELATION OF THE EXTENT OF ABSORPTION 

TO THE DANGER. 

PROBLEM: Is the danger proportional to the evidence 

of absorption of bone about the apex of a suspected tooth? 

EXPERIMENTAL AND DISCISSION. 

We perhaps should be expected to apologize for the presump- 
tion that there may be any question as to the truth of this so gen- 
erally accepted premise. Probably in every city of any size in the 
country there are to be found would-be dental diagnosticians 
whose preparation presumably makes them competent to judge 
the difference in size of different areas with the naked eye, without 
a mathematical calculation, with considerable definiteness, but 
who have no qualification which would make it possible for them 
to interpret pathology in any other terms than dimensions. We 
must state frankly that this particular study was not inspired by 
any antagonism to these persons as a group, but solely in the 
interest of humanity. The fundamental basis for the procedure 
in the great majority of the laboratories of the country (and it 
is pathetically true that there is so great a majority of diagnostic 
institutions of the country undertaking to do dental diagnosis 
without the assistance of a trained dental pathologist) is to look 
in the roentgenogram for an area of radiolucency, and, if one be 
found, to judge its probable volume and extent, which factors 
alone determine whether that tooth is or is not potentially a pos- 
sible source of danger to that patient ; and in direct proportion to 
the volume will the danger be interpreted to be. We have, ac- 
cordingly, classified fourteen hundred individuals in terms of their 
type and extent of absorption, both apparent and actual, in com- 
parison with the presence and absence of systemic involvements. 

In Chapter 5, when discussing the relationships between the 
characteristics of local structural change about infected teeth, 
and tendency to systemic involvement, I presented a series of 
cases as characteristic of the groups. While these did show those 
facts very strongly, and in accordance with the large number of 
cases involved in the various groups, they were not comparable 

167 



168 DENTAL INFECTIONS, ORAL AND SYSTEMIC -RESEARCHES— VOL. I 



Figure 92. Laterals with putrescent pulps. Absent susceptibility. 

infections in the sense that they were either the same type of in- 
fection or the same tooth. For example, areas of disturbance 
about root-filled teeth represent not only different sizes of teeth 
and numbers of roots, but a different capacity for infection within 
the tooth structure. Accordingly, if we can take a definite 
quantity of infection, such as would obtain with a lateral tooth 
with a non- vital pulp, and study it comparatively in different 
individuals, it becomes immediately possible to make comparisons 
with greater safety. In Figures 92, 93, 94, and 95, we have 
selected a series of infected laterals, which teeth had evidence 
of being non- vital for a considerable time. 

Since the problem involved in this special research is to deter- 
mine the relationship between the systemic involvement and the 
local expression, and whether the latter in its extent is directly 
proportional as a danger with that extent, it becomes immediately 
necessary that our study include a very careful analysis of the 
patients having, or not having systemic involvement, and of the 
same having evidence or proof of the dental focus as being a prin- 
cipal cause by the patient's being definitely relieved of severe 
symptoms by the removal of that dental focus. 

When, now, we make a careful study of the systemic reactions 
and check them against these tissue expressions, we find that those 
in Figure 92 are free, and have always been free, from systemic in- 
volvements of the rheumatic group; in other words, belong to our 
group which we spoke of as absent susceptibility. Those in 
Figure 93, we find, have both been free during their lifetime until 



CHAP Ml RELATION OF EXTENT OF ABSORPTION TO DANGER L69 




Figure 93. Laterals with pi trescent pulps. Acquired susceptibility. 

recently when they have had a sudden severe attack which has 
been entirely and permanently relieved by the removal of this 
dental focus. These patients belong to, and these illustrations 
are taken from, the group having an acquired susceptibility ac- 
cording to their systemic condition. Those in Figure 94, similarly 
belong to those with mildly inherited susceptibility; and those in 
Figure 95, with very little evidence of absorption about apices of 
infected teeth, all belong to the group which, according to their 
histories, have had serious involvements and have had a strong 
inherited susceptibility from both sides. 

A clinical comparison of these individuals who represent 
different large groups reveals that those in Figure 92 have all the 
infection of a putrescent lateral pulp as have all the others, not- 
withstanding the fact, that they have never had any of the degen- 
erative diseases which we speak of as rheumatic group. Fortu- 
nately these two individuals represent a large group of the total of 
society. During long periods of their lifetime their defense is 
ample to protect them against this and their various overloads 
and, as is so frequently seen, protects them against many such 
infected teeth. These two individuals are selected from the 
group of fifteen presented in Chapter 4, classed as those with 
absent susceptibility. The average number of severe rheumatic 
group lesions for the entire family represented by this group was 
found to be 1.07, and the severe and mild rheumatic group le- 
sions 2.07. It will be remembered that, on an average, there are 
fifteen individuals included in the family circle of the ancestry. 



170 DENTAL INFECTIONS, ORAL AND SYSTEMIC-RESEARCHES -VOL. I 




Figure 94. Laterals with putrescent pulps. Mildly inherited susceptibility. 

The next two laterals, shown in Figure 93, are taken from the 
group with an acquired susceptibility. A is the lateral of a patient 
who has had a very unusually high defense all his lifetime until 
he was a victim of influenza. This lateral tooth had had a fistula 
for some time. With the onset of his Flu and following it, he 
suffered very severely from neuritis. This tooth was treated and 
root-filled and an apical curettement made, following which his 
neuritis promptly disappeared. Figure 93-B shows a different con- 
dition structurally in that there is a distinct tendency to the for- 
mation of limiting dense bone surrounding the rarefied area. 
This patient had been suffering for several weeks from rheuma- 
tism. This tooth was extracted and carried on a pinlay on the 
lingual surface of the cuspid. Her rheumatism seemed to be com- 
pletely relieved by the removal of this tooth. These two individ- 
uals are typical representatives of the group which we have 
termed as having an acquired susceptibility. They, as a group, 
have had a high defense until an overload has broken them suffi- 
ciently so that they become a prey to their own infections, which 
previously they had carried without apparent injury. With the 
removal of their overloads or their dental infections, and particu- 
larly with the removal of both, they tend readily to come back to 
their own high normal. The individuals of this figure were se- 
lected frcm the group of fifteen, representing those with an ac- 
quired susceptibility, in which it was seen that the average total 
severe rheumatic group lesions of the entire immediate and an- 
cestral relatives was 4.20, and the severe and mild 6.40. 



CHAP. XII RELATION OF EXTENT OF ABSORPTION TO DANGER 171 

Figure 94, A and B, shows two individuals with a mildly in- 
herited susceptibility. They have tended more or less readily to 
have mild rheumatic group lesions with overload and infection. 
Whereas in the two former groups during the period of high 
defense, teeth tend readily to become tender and apical infec- 
tions of this type nearly always have fistulae, in this group there is 
much less apical absorption for a given infection, less tendency 
to have a fistula, and less tendency to tenderness. With the re- 
moval of these dental infections which were of long standing, the 
results were as follows: 

The patient represented in A, a married woman, age twenty- 
nine, had a severe nervousness following the death of her husband 
from influenza, from which she would cry on the slightest provoca- 
tion, and had been incapacitated from her work, since she had to 
earn to support their four year old child. With the removal of her 
dental infections there was a rapid marked improvement in all of 
these nervous symptoms. She was able to take up her duties again 
and the world looked entirely different. However, just as grief is 
one of the greatest depressants and overloads, joys are among the 
most potential stimulants ; and it is possible that one of the con- 
tributing factors to her vivacity and rapid return to health 
(although it is my belief that it came after this change in her 
physical condition) may have been the fact of a change in her 
life's responsibilities by a new engagement and a remarriage. 
Indeed, it is entirely probable that this happy change in her life 
could not have come for a long time, if at all, if it had not been by 
the remarkable change that was wrought by the removal of her 
dental infections. In these cases we have a combination of ac- 
quired factors superimposed upon the normal inherited tenden- 
cies. From her roentgenograms we would readily see that this 
woman's condition is indicated to be one of good reacting power 
and probably high defense. While this patient suffered from ner- 
vous breakdown, one of her sisters had a similar though less severe 
experience, and her mother and one of her mother's sisters had 
suffered very severely from nervous troubles. The health record, 
however, on the father's side was excellent, there having been no 
lesions of the rheumatic group recorded. 

Figure 94-B is a case of a man forty-seven years of age, who has 
ordinarily had excellent health, but has recently suffered very 
severely from neuritis in his shoulders. With the removal of his 
dental infections, which were very extensive and of long stand- 



172 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

ing, his neuritis entirely disappeared and has not returned, even 
in mild form for two years. This is a case where the factor of 
overloads was very important. This man had had very extensive 
dental infections. With the depression following the war, his 
business anxieties became very great. Rheumatism and neuritis 
had been mildly inherited from both his father and mother, and 
we should, accordingly, consider his case as being one of an ac- 
quired susceptibility superimposed upon a mildly inherited one. 
This is also indicated by the type of dental pathology revealed 
about his infected teeth, there being a zone of marked condensing 
osteitis surrounding the rarefying. The individuals of this group 
tend much more readily to have breaks from overloads than those 
in the two preceding. The susceptibility group to which they 
belong is mildly inherited, in which group of fifteen families we 
have found the average number of severe lesions per family 
group, inherited one side mild, to be 9.6, and the severe and mild, 
13.4; and inherited two sides mild, 15.3 and 20.5. 




Figure 9o. Laterals with putrescent pulps. Strongly inherited susceptibility. 



Figure 95, A and B, shows two cases from the strongly inherited 
susceptibility group of fifteen (in which group we have the aver- 
age number of severe lesions per family group, inherited one side 
strong, to be 17.2, and the severe and mild, 22.5; and inherited 
two sides strong, 32.2 and 50.2) who are quite typical of that 
group. They are both young people. Each has a putrescent 



CHAP. XII RELATION OF EXTENT 01 ABSORPTION TO DANGER 1 7!i 

pulp in a lateral tooth. There is no fistula and never has been. 
The teeth arc not sore and never haw been, or but slightly. 
There is a very slight area of absorption about the apices of the 

roots. A has a type of nervous breakdown and rheumatism, and 
has been incapacitated from her work, or nearly so, approximately 
half the time for several years. This is only one of several dental 
infections that were removed, one at a time; and after complete 
removal of her dental infections, she has had very much better 
health and has scarcely lost a day from her work because of ill 
health for three years. B had a very severe heart involvement 
and rheumatism, which had completely incapacitated her from 
her work for several months. With the removal of this and other 
dental infections she very soon gained twenty pounds. Her 
heart is apparently normal in function again and her rheumatism 
entirely disappeared so that for several years she has not lost any 
time from this cause. A had previously had an operation for the 
removal of tonsils and appendix without beneficial result. 

Each of these two individuals comes from a family with very 
marked susceptibility to the lesions from which they are suffer- 
ing. Both of the parents of B died in the fifties of heart involve- 
ment after years of incapacity. A has some heart involvement. 
Her brother died of heart involvement as did her father, who also 
suffered severely from rheumatism. They are quite true to type 
for their class. The type of reaction about the apices of the roots 
shows progressively less destruction of alveolar tissue about the 
apices of the infected pulpless teeth; and with the decrease in 
apical absorption and the absence of fistulae, there is an increase 
in the susceptibility to systemic involvement, or a decrease in the 
patient's safety. This is precisely the opposite to what is taken 
for granted by the casual observations and as the general basis 
for the interpretation of dental roentgenograms. 

And just at this point I wish to anticipate a misapprehension 
that is likely to occur. Individuals reading this must not quote 
this statement except in connection with the premises on which 
these observations are made and the comparisons given : namely, 
that with a given dental infection the apical reaction is progres- 
sively less with the decline of that individual's defense against 
that infection. In all these individuals, or more specifically 
stated, in any individual of any of these groups a larger quantity 
of infection will produce a greater local reaction of the type char- 



174 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

acteristic of that individual than a smaller quantity. Or other- 
wise stated, in any individual of any of these groups a tooth, with 
the quantity of infection so large as that involved with an entire 
infected pulp in addition to the infected dentin, will have a larger 
zone of disturbance about the apex of that tooth, than about 
some other tooth with a partial root-filling, and these two greater 
than some other tooth with an excellent root-filling, and all these 
three more than a tooth with a very recent suitable sterilization 
and root-filling. Accordingly, an individual with a very high 
defense and a very excellent reaction will show as much apical 
disturbance about a tooth with but slight infection, as an individ- 
ual with a very low defense will about a tooth with a very large 
quantity of infection. We have, then, two important factors. A 
given amount of disturbance at a root apex will represent two 
entirely different quantities of infection with these different 
groups, and the danger to the individual having that given quan- 
tity of apical disturbance will be an entirely different matter, if 
she or he belong to the group having a very high defense, from 
that if they belong to a group with a very low defense, and these 
again will be directly related to their overloads. 

We have made a careful study of the data disclosed in our 
records of case histories and find that in 681 selected cases having 



RELATION OF LOCAL TO SYSTEMIC 






Local Expressions 


No. of Lesions 




of Dental Infections 


per 


Group 


Susceptibility Class 






2 








§ 




ies 

rrhea 

n 

ked 

efyin 

idensi 


u 
V 


°3 

CD 




l_ O <U U U G 


> 


> 




rcs >, O. o cq o 


OJ 


cu 




O CU O J Cd u 


C/3 


tf) 


Averages of Total No. 


75 23 25 75 32 26 


170 


245 


Groups of 15 








Absent 


40 40 40 60 67 


16 


31 


Acquired 


80 33 33 87 33 20 


63 


96 


Inherited 


67 33 40 87 33 20 


144 


201 


1 side mild 








Inherited 


93 20 27 80 40 33 


227 


308 


2 sides mild 








Inherited 


80 20 20 80 27 33 


258 


338 


1 side strong 








Inherited 


93 87 7 67 


483 


754 


2 sides strong 









Figure 96. 



CHAP. XII RELATION OF EXTENT 01 ABSORPTION TO DANGER L75 

adequately complete histories, the average number of open dental 
infections, by which we mean infected pockets at the gingival 
margin of the teeth extend ng at least a third of the distance at 
the apex, or apical abscesses with fistulae, the average percentage 
of all types is 25, and the average percentage with apical infe< 
tions without fistulae, termed locked infections, 75, the percent- 
age with rarefying osteitis 32, and the percentage \\ ith condensing 
osteitis 26. (See Figure 96. 

When we select groups of fifteen from each of the six different 
degrees of susceptibility and compare the percentages for these 
four local conditions, we find for the absent group: open 40, 
locked 60, rarefying 67. condensing 0; the acquired susceptibility 
group: open 33, locked 87, rarefying 33, condensing 20; inherited 
susceptibility, one side mild: open 40, locked 87, rarefying 33, 
condensing 20; inherited susceptibility, two sides mild: open 27, 
locked 80. rarefying 40, condensing 33; inherited susceptibility, 
one side strong: open 20, locked 80, rarefying 27, condensing 33; 
inherited susceptibility, two sides strong: open 0, locked 87, 
rarefying 7, condensing 67. 

From this it will be seen that there is a progressive change in 
the type of reaction directly in proportion as the susceptibility 
changes; the condensing osteitis progressing from in the absent 
group to 67 per cent in the inherited two sides strong ; and the 
rarefying osteitis decreasing from 67 per cent in the absent to 7 
inherited two sides strong; and, similarly, the open decreases from 
40 in the absent to in the strongly inherited, and the locked in- 
creases from 60 in the absent to 87 per cent in the strongly in- 
herited. 

When we compare these figures with those in the next column 
—namely, the clinical expression of the rheumatic group lesions- 
called the Number of Lesions per Group, expressed as severe, 
and severe and mild, we have for the group with absent suscepti- 
bility as a total number of severe lesions in all or each one of 
fifteen individuals and all the members of their families — 16, 
severe and mild — 31 ; acquired susceptibility — 63 and 96; inherited 
one side mild — 144 and 201 ; inherited one side strong — 258 and 
338; inherited two sides mild — 227 and 308; and inherited two 
sides strong — 483 and 754. 

SUMMARY AND CONCLUSIONS. 

A study of the 681 selected cases from the 1400 here reported 
indicates to us that the danger is not in proportion to the area of 



176 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

apparent or actual absorption about root apices, and that it tends 
more nearly to be in a reverse order to the area of absorption pro- 
duced by a given infection. Our interpretation of this is given 
in succeeding chapters. 

This is a most important and striking discovery, and particu- 
larly so since the individuals recording these data and summariz- 
ing them had not the remotest conception of what was developing 
or its significance. It is a most singular fact that the presence of 
condensing osteitis in these groups should progress practically in 
direct proportion to the susceptibility to rheumatic group dis- 
turbances in the other members of the family as well as in direct 
proportion to the susceptibility in the individual. The former 
is a fact of profound significance. It is a very different thing that 
the type of local dental pathology should be related to these quali- 
ties in the other members of his or her family. We are therefore 
dealing with common effects of general causes. 

We would therefore state the fundamental on which this re- 
search is based as follows: 

Since different people react differently through a 
wide range to a given infection, the quantity of the 
absorption is not a measure of the danger but, on 
the contrary, it may be, and frequently is, true that 
the patient suffering severely from a systemic reac- 
tion caused by a dental infection, shows very little 
absorption compared with that which the same 
dental infection would produce in a patient with 
ample and high resistance. 



CHAPTER XIII 

THE NATURE OF THE DISCHARGE FROM A DENTAL 

FISTULA. 

PROBLEM: Is the discharge from a chronic denial fistula 
badly infected and i'( ry poisonous? 

EXPERIMENTAL AND DISCUSSION. 

Pus has been synonymous in the thinking and teaching of 
dental problems with eoncentrated virulent infective organisms, 
so much so that until recently it has been thought that teeth 
with fistulae draining apical abscesses were not only the most 
dangerous but, until the advent of the Roentgen-ray, constituted 
nearly the entire group of so-called abscessed teeth, and there- 
fore the cure of the pathological lesion in question depended 
entirely upon the skill of the operator. The proof that the 
abscess was cured was the closing of the fistula. 

Years of experience in oral surgery revealed that practically all 
of the teeth that were removed as border-line, proved to be seri- 
ously involved at the apex, though without a fistula. For years 
it was deemed that teeth were not bad enough to be border-line 
if they did not have a fistula; but if they were not bad enough to 
have a fistula, it was taken for granted that they were all right, 
that they were of necessity not badly infected; and those with 
fistulae were presumed by many operators to be incurable or not, 
depending solely upon the skill of the operator, and particularly 
on the magic secret formula which he possessed, mest of which 
teeth required many and long treatments according to the ideals 
of those days. This phase of the problem, namely medication, is 
discussed in the next chapter. It is possible that even today it is 
well nigh universally believed by the members of both the medi- 
cal and dental professions, and for that matter the laity also.that 
teeth with flowing fistulae have the same only because they are 
more severely and extensively infected than the teeth that do not 
have fistulae. In other words, the presence or absence of a fistula 
is a measure of infection. 

This problem has to do with the nature of the material flowing 
from chronic dental fistulae. The method of procedure has been 



178 DENTAL INFECTIONS, ORAL AND SYSTEMIC -RESEARCHES— VOL. I 



% 










1 *<u i 






-*m ;- 

\** 

Figure 97. Discharge from a fistula of a patient who has a high defense. 

to take by aspiration, material from the fistulae and study its 
contents both in living and stained mounts. Since this material 
is supposed to be made up, in addition to the leucocytes, with 
living and dead organisms, stains were expected to show large 
numbers of organisms free in the fluid. Figure 97 is typical, being 
a Wright's stain, and it will be noted that while there are many 
polynuclear leucocytes, only a small portion of them contain 
phagocyted organisms, and there are practically no organisms 
outside the leucocytes. Many phagocyting leucocytes have only 
1 or 2, a few have 5 to 10, but the great majority do not have any. 
Plating of aspirated contents from agar media frequently reveals 
only scattered colonies, and not infrequently aspirated material 
from dental fistulae, cultured in suitable media, proves sterile. 

Let us now study the patient from whom the pus was taken 
from this flowing fistula. The roentgenograms of the teeth are 
shown in Figure 98. She is forty-six years of age, with a very un- 
usual physique, in that she has never had any of the rheumatic 



CHAP. XIII NATURE OF DISCHARGE FR< >M DENTAL FISTULA L79 

group lesions, nor have any of the members of her family. She 
has several poorly filled root canals, which if they had been in the 
mouth of an individual with low defense and marked rheumatic 
group susceptibility, would have had very little apical disturbance' 

and no fistula. But in her ease practically every imperfectly root- 
filled tooth shows extensive apical alveolar absorption. She has 
listulae both in the hard palate and through the buccal mucous 
membrane, has frequent swelling, will feel very miserable for a 
day or two while fighting the acute attack, and with its subsidence 
rebounds quickly to her normal high defense and excellent health. 
She is relatively safe so long as she has this undisturbed high de- 
fense; and since her normal by inheritance is so high, only a severe 
overload will break it. Any of the severe overloads which we dis- 
cuss later, such as influenza and pregnancy, would tend to make 
her splendid defense less complete and her factor of safety would 
be definitely reduced, perhaps to the danger line. This type of 
individual should live to be ninety or one hundred, with good 
health to the end. She may develop nephritis, hypertension, or 
other degenerative diseases as her defense gees down with advanc- 
ing years; and since the chain is no stronger than its weakest link, 
her efficient and healthful life term may be reduced a decade or 
two or three by the presence of these very dental infections, for 
she will go into the class with an acquired susceptibility. 

We will later discuss, but will anticipate here, the type of in- 
dividual furnishing most favorable conditions for the various 
operations such as root-filling, apicoectomy, etc. It will, however, 
be readily seen that if such operations are to be made, they will 
be much more favorable of success in the individuals with the 
high defense, as we have outlined it, than those with the relatively 
low defense. In other words, such an individual as we have 
shown here, could doubtless have root fillings made in these roots, 
and root resections, and be relatively safe in carrying these teeth 
for a few years because of her normally high defense, not only be- 
cause of the operation that might be made but, in fact, in spite 
of any dental operation that might be made. We will later dis- 
cuss in further detail the many overloads that may come suddenly 
and make the individual suddenly susceptible to the infections 
to which he has previously been relatively immune. 

This quality of the nature of the discharge from a fistula varies 
greatly with the stage of the break or absence of break in the de- 
fense. We have very frequently seen, and this can be observed 



180 DENTAL INFECTIONS, ORAL AND SYSTEMIC -RESEARCHES— VOL. I 




z 



O 

faj 
CJ 

< 

as 

< 

0, 
< 






CHAP. XIII NATURE OF DISCHARGE FROM DEN rAL FISTULA IM 

in many mouths, the scar ol a fistula which has closed, not be- 
cause the conditions have become better though they apparently 
have, since the Mow has stopped, but because the conditions have 
become worse. Very main- fistulae close, following an attack of 
influenza. In subsequent chapters I will discuss some qualities 
of the mechanisms involved. Incidentally, it has been because 
of the finding in the clinics, particularly the' outpatient clinics of 
hospitals, of large numbers of individuals with flowing pus from 
fistulae about broken down and carious roots and no rheumatic 
group lesions, the patient having come because of a specific infec- 
tion or traumatic injury, that large numbers of the medical and 
dental profession have concluded that if people with so much 
dental infection as these individuals apparently had, do not have 
rheumatic group lesions, then dental infections are not capable of 
producing so serious disturbance as some of us have claimed. In 
other words, these expressions of defense have been mistaken for 
evidences of quantity of infection. I would ask the reader to look 
again carefully at the root fillings in the teeth showing these large 
apical areas in Figure 98, and compare the quantity of infection 
possible in these teeth with the quantity available with an entire 
putrescent pulp, as shown in the various individuals in Figures 92, 
93, 94. and 95, in the preceding chapter. 




Figure 99. Smear from root apex of tooth of flowing fistula. 

Only phagocyted organisms are seen. 

A smear from the apex of a root of a tooth with a flowing fistula 



182 DENTAL INFECTIONS, ORAL AND SYSTEMIC -RESEARCHES— VOL. I 




J/J. 






;> -- - ~ 
■ i ■ 
















At 

Figure 100. A profuse phagocytosis from a flowing fistula. 

shows practically no organisms except those few that are phag- 
ocyted. (See Figure 99.) In this instance the smear does not 
show a large number of leucocytes. Some other cases do show a 
very profuse infiltration of leucocytes with a large proportion of 
them phagocyting leucocytes. This is illustrated in Figure 100. 
Figure 101 shows a smear from the root of a tooth without a dental 
fistula, and while it is not necessarily typical of all the various 
types of apical involvement without fistulae, it is typical of a 
very large number; and in it, it will be seen that there are large 
numbers of organisms free in the fluid and not yet phagocyted, 
beside those contained in the phagocyting leucocytes. This 
would appear to be quite the reverse condition to what is general- 
ly expected to obtain, though we will see in the discussion of this 
phenomenon that it is what we should really have expected if our 
interpretations are correct. 






CHAP. XIII NATURE OF DISCHARGE FROM DENTA1 FISTULA 



is;; 



I 




• 




n: 



o 



* 



.t 



Fkji-re 101. Smear from apex of a tooth without a fistula. 



We would, accordingly, restate the fundamental, which has 
generally been thought of about as follows : namely, that flowing 
pus from a fistula is necessarily very dangerous to the patient, 
to the following: 

Since an adequately active defense against a dental 
infection produces a vigorous local reaction with at- 
tending extensive absorption, and the products of 
inflammatory reaction — namely, exudate and plas- 
ma in sufficient quantity to require an overflow, 
usually spoken of as pus from a fistula this over- 
flow may be, and usually is, evidence of an active de- 
fense and is constituted almost wholly of neutral- 
ized products, and is often sterile; and such a con- 
dition is much more safe than the same infected 
tooth without such an active local reaction. 



CHAPTER XIV. 

EFFICIENCY AND HARMLESSNESS OF ROOT CANAL 

MEDICATIONS. 

PROBLEM: Can injected pulpless teeth be readily steri- 
lized by root medication? 

EXPERIMENTAL AND DISCUSSION. 

A search of the literature of the dental profession reveals the 
fact that for seventy-five years there have abounded formulas 
which were considered competent to sterilize infected teeth. 
Practically all authors, prior to the last decade, seem to have 
taken for granted that teeth properly treated were rendered 
sterile. A criterion that seemed to be dependable — namely, the 
comfort of the teeth — seemed to guarantee the success of this 
operation since infected teeth were expected to become painful 
and abscessed if they were not completely sterile. The relatively 
small percentage that did become painful were interpreted to con- 
stitute the group that had not been adequately sterilized. This 
research was undertaken to establish, by means of experimental 
data, the soundness of that conclusion, and with the full confi- 
dence that the experiments would corroborate and establish the 
general presumption to be a fact. 

Figure 102 shows a series of roentgenograms of the same tooth, 
treated by me in 1901, at which time I sterilized the tooth accord- 
ing to the regulation methods of the time ; and in accordance with 
the roentgenograms, since the periapical area diminished and 
there was apparent deposition of bone with a condensing of the 
bone about the apex, I seemed justified in concluding that my 
operation had been a success, since I put in an up-to-date root 
filling extending to the apex. Owing to the patient's having a 
progressive type of deforming arthritis, I later, in 1916, sent for 
her and on the strength of our accumulating experience extracted 
this and some other teeth. Note that the bone, as shown in A, B, 
and C, had become continually more dense about this tooth. 
Upon its extraction, and at which time it was not in the least 
tender, nor had it been since its treatment fourteen years pre- 
viously, cultures were made at the apex of the tooth, internally 

181 



C ll \r. \l\ -EFFK II \«. , > OF ROOI «. \\ M MEDK VTIONS 



\K, 




Figure 102. Changes in radiolucency about same tooth, second bicuspid, 

in fifteen years. patient has deforming arthritis a, taken in 1901, 
B in 1914. C in 1916. Return toward normal after extraction shown in 
D. 1920. IN E. 1921. in F. 1922 and in G. 1923. 

and externally. Before extraction a curetting was made to the 
bone at the gingival margin with an actual cautery, and the 
tooth was found profusely infected with a strain with definite 
tissue affinity qualities; and more, not only was the root infected 
through and through, but the bone for considerable distance 
about the tooth, as reported in Chapter 3. 

Because of many experiences corresponding to that just cited, 
we planned a series of experiments that were intended to demon- 
strate why we failed in such cases as the above. One of the 
earliest tests was to place in the roots of teeth sterile root dress- 
ings, carrying various medicaments which were left sealed in the 
root for various periods of time. This first series was all done on 
patients; and to our complete amazement, in practically all dress- 
ings that were left in roots forty-eight hours, and with most of 
them after twenty-four hours, the apical third of the dressing 
was found infected regardless of what the medicament was that 
was placed on that dressing, provided there was an apical involve- 



186 DENTAL INFECTIONS, ORAL AND SYSTEMIC-RESEARCHES- VOL. I 

ment about the root. These studies suggested that there was a 
quantity effect that was very important : namely, that we were 
not able to put into the root of a tooth, sufficient medicament to 
overcome the nutrient effect of the fluid within the tooth, and 
surrounding the tooth, regardless of the medicament. We ac- 
cordingly tested the relation of tooth mass to medicament vol- 
ume, by placing blocks of infected tooth substance in relatively 
large quantities of medicament, and found that, in over a hun- 
dred medicaments and dilutions of same even under the very 
unusual conditions in which a large mass of medicament was in 
contact with both the inner and outer portion of a section of 
tooth root, and where medicaments of strengths were used which 
clearly would be prohibitive in the mouth, because of their de- 
structive action on the adjoining vital tissues the cementum and 
dentin were not disinfected except with a very few medicaments: 
namely, formalin in all strengths, iodin 5%, and chlorophenol. 
It was found, however, that many medicaments exerted inhibit- 
ing effects where organisms often grew out days or weeks after 
being transferred from the medicament to culture media. 

The next series of experiments was made to determine the ability 
of medicaments to maintain the sterility of the root-dressing 
when sealed in an infected root and without the perforated root- 
apex's being immersed in an infected culture medium. The 
medicaments found most promising in the preceding experiment 
were used for these tests: namely, formocresol, iodin-creosote, 
iodin 7%, formalin concentrated, phenol 5%, cloves 50%, sul- 
phuric acid 50%, thymol, mercurophen, chloralhydrate, hydro- 
gen dioxide, creosote, alcohol 70%, chlorophenol, phenol com- 
pound, chlorazene 4%, dichloramin 15% , and phenol saturated. 
In these it was found that the most radical disinfectant was 
dichloramin-T used in saturated form; but in this strength was 
found to be exceedingly irritating when used in conditions of the 
mouth, often producing great pain and irritation of the supporting 
tissues. At that time we made a note : 'The members of the pro- 
fession are warned never to place the 15% or even a 5% solution 
of the Dichloramin-T in oil of Eucalyptol, its solvent, in any 
tooth or on tissues." 

Of the 18 medicaments used for this experiment, only 6 gave 
instances of negative results in cultures; or, in other words, were 
efficient ; the remaining all gave positive cultures in every case for 
the complete series of hours run. The five best results are shown 



5Hrs. 


24 I Irs. 


18 Mrs. 


100' i 


KM)', 


KM)', 


81$ 


25< i 




SI', 


50', 


<)', 


75' , 


94$ 


:;?', 


56', 


62< ; 


6$ 



CHAP.XIV EFFICIENCY OF ROOT CANA1 \lll>k\ll<>\^ is? 



I ttchloramin-T 

lodin Creosote 

Phenol Compound 

Formalin 

Formocresol 
in Figure 103. 

The next experiment was made to determine the ability of the 
medicaments to maintain the sterility of the root dressing when 
sealed in an infected root, when the perforated root apex is im- 
mersed in an infected culture medium. For this experiment, 
forty medicaments which showed the most encouraging results 
in experiment No. 1 were tested, and the efficiency of the various 
preparations determined by placing the dressing carrying the 
medicament in the root canal with its small perforated apex cor- 
responding with the small open foramen, and the tooth so pre- 
pared, itself an infected root, was placed in a container in which 
was placed a small quantity of infected culture media which came 
in contact with the apex of the tooth, the tooth crown being 
covered to the cementum, after it was dried, with paraffin. Of 
the forty medicaments used, only eight gave negative results, the 
remainder being all positive in every trial and for all periods of 
time. The length of time the medicament was left in the tooth 
was found to make a very great difference. This test was not 
made to determine the ability of the medicament to sterilize 
tODth structure, but rather the ability of the medicament to 
maintain the sterility of the sterile J. & J. absorbent point on 
which it was placed in the tooth. The points were removed under 
sterile conditions and cut into sections 1, 2, 3, and 4, numbering 
from the root apex up. 





5Hrs. 


24 Hrs. 


48 Hrs 


Phenol Compound 


70', 


15% 


0', 


Dichloramin-T 15% 


35% 


5', 


<>', 


Formocresol 


34', 


0', 


(>', 


Iodin-Creosote 


33', 


25% 


<>', 


lodin U. S. P. 


10', 


34% 


o\ 


Formalin U. S. P. 


0', 


34% 


0', 


Phenol U. S. P. 


o c '< 


45% 


o\ 


Oil of Cloves 


o c < 


25% 


<>', 



Figure No. 104 shows the result of the eight best of the forty: 
All were infected in forty-eight hours, nearly all in twenty-four 
hours, and a few had some efficiency, if tested within five 
hours. 



188 DENTAL INFECTIONS, ORAL AND SYSTEMIC -RESEARCHES— VOL. I 

Experiment No. 4 was made to determine the ability of medic- 
aments to sterilize infected dentin and cementum when sealed 
in the root canal, and when the perforated apex is surrounded by 
infected culture medium, as in the conditions in Experiment 3. 
Note the difference that in this experiment we are determining the 
influence on the dentin and cementum ; whereas, in the former, we 
are testing the ability of medicaments even to maintain the 
sterility of the root canal dressing. After the test was made on the 
teeth, as in the previous experiment, the teeth were divided longi- 
tudinally with precautions to prevent contamination, and cul- 
tures were taken with fine-pointed burrs, properly controlled 
against contamination, from various structures in various parts 
of the tooth. The results of these experiments were that with 
the exception of concentrated formalin which showed 93 c c steril- 
ity, all of the teeth showed a general infected condition of the 
various tooth structures, and even formalin 5% had a very low 
efficiency. 

Tests were made similarly with double salt of ammonium 
silver and formalin. Four series were run. Series 1 gave an 
efficiency of 69% ; Series 2, 78% ; Series 3, 84% ; and Series 4, 95%. 

The general result of these studies was summed up under 
"General Summary and Conclusions" as follows: 

"1. Infected dentin and cementum are not readily sterilized 
by medication, even when the amount of medicament is largely 
in excess of the mass of tooth structure. 

"2. The medicament contained in a medicated root dressing 
very readily and rapidly loses its disinfecting power, for the 
dressing itself becomes infected in a few hours, even from the in- 
fected dentin and without being in contact with an infected solu- 
tion. 

"3. The medicament in the dressing dissipates more rapidly 
when one end of the dressing is in contact with an infected culture 
medium, such condition as obtains in a periapical infection. 

"4. The efficiency of a root treatment is greater a few hours 
after it has been placed in the tooth than several days', or even 
one day's time. 

"5. All areas of cementum and dentin are difficult to sterilize, 
as well as tend to reinfection, when the medicated root dressing 
is left more than a few hours. 

"6. The medicaments that are most efficient, namely, silver 
nitrate and formalin, are very objectionable, the former by its 



CHAP. XH EFFICIENCY 0FRCOTCANA1 MEDICATIONS 189 

discoloration and the latter by its destructing and irritating 
properties, except when used very dilute and for a short time and 
then quite efficiently. 

"7. There is much encouragement in the use of Chlorazene 
chloramm-T) and E)ichloramin-T products. The latter, however, 
is exceedingly painful and destructive in over half of one per cent 
strength. 

"8. We now understand why it has been, that if a root treat- 
ment is left in the tooth for an extended period of time, it becomes 
foul in odor. Also a verification of the observation previously 
reported by one of us. Price, to the effect that medicated root 
dressings will always show bacterial growth after they have been 
left in infected teeth for a few days. 

"9. These determinations indicate to us that an exceedingly 
small per cent of the teeth, that have been treated by members 
of the dental profession in the past, have actually been sterilized. 

"10. Nature is, and has always been, very tolerant, and much 
of the credit that has been taken by, and given to, the dental pro- 
fession for the sterilization of infected roots, has really been due 
to Nature for her kindness in tolerating, at least without local 
irritation, a probably almost universal and permanent condition 
cf infection, though in lessened amount, when tooth structures 
have once been infected and have been subjected to treatment." 

These experiments were made under my direct supervision, 
partly by myself and partly by an assistant, Mrs. Matilda Mold- 
enhauer Brooks 4 in the Research Institute of the National Dental 
Association, in which I was Research Director; and a full report 
will be found in detail, in the Journal of the National Dental 
Association, Volume V, No. 3, March 1918, pp. 273-303, which 
report was read before the National Dental Association at its 
Twenty-First Annual Session, New York City, October 1917. 

We have run many controls and parallel experiments, and have 
found that the one that seemed to give most satisfying results in 
our hands has been chloramin-T (not dichloramin-T) which can 
be used in saturated aqueous solution in paste form, is soluble in 
water up to about 8 to 12 r f (Dichloramin-T is not soluble in 
water), does not discolor the teeth, and by being used as a paste, 
has so much reserve material for sterilizing that it retains its 
efficiency for a longer time than most of the preparations, and is 
not particularly irritating unless there be considerable vital pulp 
tissue within the root. The silver formalin, or the silver precip- 

4 See bibliography. 



190 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES -VOL. I 

itated by other means, as for example eugenol, has high efficiency 
where it can be used, but produces marked discoloration. 

In addition to the above studies, we have carefully cultured 
many teeth after we had thoroughly treated them, with the hope 
and expectation of retaining them in the mouth; but later decided 
to remove them; and, in practically all cases where teeth had 
been putrescent and had evidence of periapical involvement, 
though slight, we practically always failed to sterilize cementum 
at the apex, and frequently had positive growth from the dentin. 

Another phase of this problem has been the checking of the 
more improved methods of sterilizing infected tooth structures 
within the mouth, since it has been claimed' that by testing the 
tooth which had been sterilized, it was possible to determine whether 
or not that process had been complete . 1 1 is advocated , for example , 
by some authorities, that if a canal point saturated with culture 
medium is placed in the canal after its sterilization, a determina- 
tion can be made in one, two, or several days, to determine 
whether or not sterilization is complete. In the chapter on bac- 
terial accommodation we discussed the quality which bacteria 
have of adapting themselves to environment. In our studies, 
reported previously, we found that the practise of discarding 
controls and tests at the end of one or two weeks was entirely 
misleading, for very frequently the medication had the effect of 
inhibiting growth completely for a period of several weeks. But 
this is not the only difficulty. The organisms may, under the 
stress of the medication, take on a quality which requires an 
entirely different type of medium, not only differing in nutriment 
but in oxygen tension, which qualities apparently are not adjusted 
to, nor is there a report of their having been taken into, considera- 
tion in the reports that have indicated that complete sterility 
might be depended upon, particularly if checked by this simple 
test. 

Another argument that will be made will be that ionization, 
either by means of ionizing potassium iodide, sodium chloride, or 
other solutions, will disinfect infected cementum, when applied 
through the pulp canal. This problem was very thoroughly 
studied by Pond and Price 6 . 

We have found strains in treated teeth in the mouth, for which 
we could not find any medium, on which they would grow until 

•"' See bibliography. 
<! See bibliography. 



CHAP \l\ EFFICIENCY OF ROOT CANA1 MEDICATIONS I'M 

we would place them in a sealed Petri dish, which was connected 
with another Petri dish by an hermetically sealed tube, in which 
second dish was growing a culture of an organism which rapidly 
consumed oxygen. For days no growth would appear, when 

suddenly it would start, but cease to continue to grow as soon as 
that optimum Of oxygen tension was passed. They would not 
grow in less or more than a limited range of partial tension, and 
all our efforts to grow them by regulation methods aerobically 
and anaerobically completely failed. We now believe that many 
of our early determinations, where we got negative results, were 
so only because we were incapable of furnishing the proper medi- 
um and environment. We are also sure that this applies equally 
to some of the negative work of others; and, accordingly, while 
a positive growth can only be read positive, a negative growth is 
not necessarily negative. 

As we have shown, it is exceedingly difficult to neutralize in- 
fected dentin under any circumstances, without using medica- 
ments which may in some degree endanger the supporting struc- 
tures. Such studies made on extracted teeth are open to the 
criticism, that the conditions are not the same as in the mouth, 
and therefore cannot be considered comparable, since we do not 
have the original tooth in contact with vital tissue. To overcome 
this difficulty, and to throw further light upon the matter of 
tooth sterilization, I have planted many teeth under the skins of 
rabbits to determine their effects upon the animal, before the 
tooth was medicated, for comparison with the effect of 
placing within that tooth such medication as is placed in 
teeth in the mouth. There is a great difference in the effect of 
different teeth on the rabbits when planted in this way beneath 
the skin. Frequently they are incysted and the rabbit tissue pro- 
ceeds to absorb the root. In some others, notwithstanding the 
incysting, a nephritis is slowly developed, as illustrated elsewhere. 
In still others, the dental infection or the toxic products from the 
tooth, or both, completely prevent Nature's effort to encapsulate 
the tooth, and in many instances the rabbit is dead in from one 
and one-half to a few 7 days; as, for example, we reported in 
Chapter 17 a series of over twenty-five rabbits which were killed 
by a single tooth in from one and one-half to six days, one rabbit 
living ten days. For this study I have selected teeth, which 
killed rabbits in from two to four days, after they were 



192 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

extracted from the patient, where, incidentally, there was no 
roentgenographic evidence that they were particularly serious, 
though the patient was being systemically injured by them. 
Some of the results have been as follows : 

A tooth which killed a rabbit in three days (R. 1110) was 
opened through the crown as it would be in the mouth, the pulp 
canals cleansed and a dressing placed in it of iodin and creosote. 
The tooth was placed under the skin of another rabbit which 
died in four days (R. 1115). The tooth was again opened and 
treated with the same medicament and placed under another 
rabbit's skin and it died in four days (R. 1119). Inasmuch as 
sterile teeth produce no effect whatever in rabbits, it is very im- 
portant to note that this tooth not only killed the rabbits, but 
that they began losing in weight within a few hours after placing 
the medicament, and lost approximately twenty per cent of their 
weight in two days. This amount cannot be due to the dehydra- 
tion or starvation of the animal, for it goes on progressively till 
sometimes at the time of the death of the rabbit, it will have lost 
forty per cent of its weight, and present a condition of marked 
marasmus. 

Similarly, we have tested a number of medicaments by treating 
the teeth with them before planting them under the skin of a 
rabbit, as nearly as possible as they would be treated in the 
mouth. In this way we have tested chloramin-T, silver nitrate 
neutralized with formalin or eugenol, formocresol, two per cent 
formalin and hot air, with similar results to those obtained with 
iodin and creosote as above. I have now made several hundred 
of these determinations, results of which emphasize the need both 
for a new appreciation of danger from infected cementum, because 
of the apparent difficulty, if not impossibility, for sterilizing in- 
fected cementum by treating through a root canal. The results 
so far obtained also stress the great necessity for repeating these 
tests under as carefully controlled conditions as possible, which we 
are doing as this goes to press. I will publish further details later. 

To determine the nature of radiations of a greater length but 
still in the ultraviolet range, we have studied the effect of placing 
a tooth that had proven to be fatal to several animals when 
placed under the skin, under the radiations from the water cooled 
mercury vapor quartz arc lamp, and have found a very marked 
change in the reactions of the rabbits when the tissues over the 
implanted tooth were so treated. Whereas, this tooth previously 



CHAP. \1\ HI K IENC N OF ROOT CANAL MEDICATIONS 



193 



produced a very marked leucocytic infiltration about it, there 
were practically no leucocytes, or very few, the organisms being 
present in pure culture in large numbers in the exudate of the 
tooth at the time of the death of the rabbit, and the rabbit had 
developed a very violent appendicitis and colitis, and probably 
peritonitis. Whether this change in the effect of the infection 
after the ultraviolet radiation was due to a change in the attack- 
ing power of the organism as a result of this radiation, or to a 
greater susceptibility of the abdominal viscera because of the 
depressing effect of the radiation, we are not yet able to state. 

But it may be stated, and justly so, that this does not yet pro- 
duce an experiment which is closely comparable to those under 
which operations are made in the mouth. To test this still fur- 
ther. 1 have made the following experiment: A tooth, the right 




Figure 105. Three successive views of a mandibular molar. A. before removal of 

DEGFNERATING PULP. B IMMEDIATELY AFTER ROOT FILLING, C SEVENTEEN MONTHS AFTER ROOT 
FILLING. 

second mandibular molar, with a hypersensitive and degenerating 
pulp, shown in Figure 105-A, which tooth was considered very- 
valuable to the patient, and which showed slight, if any. alveolar 
absorption at its apex, was treated with dichloramin-T, put in 
with good access in the canals for twenty-four hours, and was 
then root-filled with the result shown in Figure 105-B. Two years 
later the tooth was extracted and also one adjoining it Uhe third 
mandibular molar, the root of which was treated and refilled at 
the same time as the second molar), as a matter of precaution, 
since the patient was considered sufficiently susceptible to strep- 



194 DENTAL INFECTIONS, ORAL AND SYSTEMIC RESEARCHES— VOL. I 

tococcal infection to require protection, and because there was 
still enough sensation to pressure in tapping in the tooth, to sug- 
gest that it was not entirely normal, notwithstanding the ap- 
pearance in the roentgenogram, as shown in Figure 105-C. This 
tooth was extracted, thoroughly washed in sterile normal salt 
solution, the root divided, and each part planted beneath the skin 
of a rabbit. It will be noted that at the time of the root filling, 
there was a very slight protrusion of the chloropercha to make a 
so-called encapsulation, but there was every reason to believe 
that the roots were efficiently treated and well filled, not only 
because of the method used, but also because of the suggested 
improvement in the supporting structures of the tooth about 
the apices of the roots, as shown by the reduced area of alveolar 
absorption from a small but definite area in B, to no apparent 
area in C. The effect of these roots on the rabbits was as follows : 

To determine whether or not there was infection within the 
structure of the root, I sterilized the apex of the tooth with a hot 
instrument, searing deeply, then drilled through the seared struc- 
ture to the interior, and cultured the chips which grew out a strain 
of diplococci. After dividing the roots, they were washed thor- 
oughly in normal salt solution, and one was placed with surgical 
aseptic procedure beneath the skin of each of two rabbits. A 
purulent infection developed about each, but much more rapidly 
about the mesial root than the distal. The mesial root killed 
four rabbits in succession in an average of six days, with an aver- 
age loss in weight of twenty per cent. The distal root killed two 
rabbits in thirty days, with an average loss of thirty-one per cent. 
In another place I am discussing the result of boiling the mesial 
root, which rabbit is still living, at the time of this writing, forty- 
six days after implantation and has gained 228 grams, or 21 per 
cent. 

Great care must be taken in interpreting these results ; and it is 
only because of the large number of similar results that I consent 
to present such a striking case, for I realize fully that many men, 
who, because of their greater interest in exodontia than in dental 
pathology, will be in danger of jumping at the conclusion that 
this is positive proof that all root-filled teeth should be extracted. 
I do feel it my duty, however, to make this important informa- 
tion public, to aid in crystallizing an appreciation of the danger 
that may attend an over-confidence in the completeness of the 
sterilization of infected roots. I will state here what I have 
stressed in further detail in other chapters, that many parts of the 



CHAP \l\ EFFK IEN< V OF ROOT CANAL MEDICATIONS 195 

body are exposed to infection, and we have reason to believe con- 
tain infective germs frequently or for extended periods; but the 
condition of safety or danger will be dependent quite largely on 
the defensive factors of the patient ; and with a given tooth, some 

individuals will, I believe, be relatively safe, while others will be 
in definite danger. I am not ready to draw the line so rigidly as 

to state that all root-filled teeth should he extracted lor every 
patient or for all patients in any given time, though I do believe 
there is a limit of safety for all such teeth for each and every 
patient. I do deem it absolutely essential that very exhaustive 
researches be continued on this subject in order that we may be 
able to draw our lines with greater exactness than we can with the 
limited knowledge, though very important, that is available. I 
think I should state here that I have not seen a single logical 
presentation of data that will justify the claims of any of the ex- 
tremists, such as the so-called "hundred per centers." In Chapter 
17 on Quantity, Systemic Effect, and Tooth Capacity, in Figure 
122, I present a table showing the results of 237 implantations 
209 of which were teeth, which should give much food for 
thought for those who believe that comfort and roentgenographic 
appearance are a guarantee of the absence of tooth infection. 

I have made many tests, and have many in progress, to deter- 
mine whether, and by what means, infected teeth may be com- 
pletely sterilized by treating through the pulp canal where there 
had been definite evidence of destruction of the peridental mem- 
brane about the apex. In Figure 106 (R. 1149) there is shown a 
rabbit that died in two days with a loss in weight of seventeen 
per cent, from a tooth that had been treated with silver nitrate 
neutralized with twenty-five per cent formalin, by placing these 
within the pulp canal, but without allowing these medicaments 
to get in contact with the cementum. A shows the tooth under 
the skin and an abscess as big as several silver dollars, with pure 
culture of streptococci, as shown in B, and which I believe grew 
out from the infected cementum, which infected cementum was 
not sterilized by the silver nitrate neutralized with twenty-five 
per cent formalin. Similarly, I have passed fuming formalin 
(forty per cent formaldehyde) through the pulp canal of an in- 
fected tooth, where I had reason to believe the cementum was 
also infected, and in which I protected the external surface of the 
tooth by putting a rubber dam on both the neck and the apex. 
This material passed through the tooth with a gravity pressure 



196 DENTAL INFECTIONS, ORAL AND SYSTEMIC -RESEARCHES— VOL. I 




pq 



% ^ 




< 



1 




Figure 106. Rabbit apparently killed by the infection in the cementum of an 
implanted tooth, after dentin was treated with silver nitrate and formalin. 



CHAP. XI\ EFFICIENCY OF ROOT CANAL MEDK mONS 1 ( .»7 

of about one tenth of an atmosphere for fifteen minutes. The 
tooth was then washed with normal salt solution, also irrigated 
through the pulp chamber. Ten grams of the concentrated for- 
malin passed the tooth. After washing, an effort was made to 
remove all trace of formalin by passing a stream of air through the 
pulp canal, the apex of which was sufficiently large to pass a con- 
siderable stream. The tooth was then planted under surgical 
conditions beneath the skin of a rabbit, and an abscess developed 
containing pure culture of diplo- and strepto-cocci. It seems 
probable that the fire-wall existing between cementum and den- 
tin was not penetrated by even concentrated formalin in fifteen 
minutes' time in sufficient quantity to destroy the organism 
within the cementum. Much light is thrown upon this problem 
in the subsequent chapters on Chemical Changes in the Blood 
and The Nature of the Defensive Factors in the Blood and the 
Forces which Injure Them. 

In the physical structure of the tooth with the dentin connected 
chiefly, if not solely, with the pulp, and the cementum connected 
chiefly, if not solely, with the pericemental membrane, we are 
dealing with two structures, each sufficiently porous to give habi- 
tation to millions of organisms. We have shown elsewhere that 
the dentinal tubuli of a single rooted tooth comprise enclosed 
canals totaling approximately three miles of length, and it is prob- 
able that no dental canal exists too small for organisms to develop 
within it, but each of these two structures is formed on a practical- 
ly continuous homogeneous base, the dentin and cementum being 
backed up to each other. Whether, as believed by some, there 
are communicating channels from the lacunae and canaliculi of 
the cementum through the dentino-cemental boundary into the 
dental tubuli of the dentin, or whether the only communication 
between these two structures will be through multiple foramina, 
is not yet definitely established, though several conditions suggest 
one or the other of these answers to be correct. 

In order to throw light upon this important problem I have 
placed infected teeth, as they were extracted, in culture media 
sufficiently hardened with agar to localize the bacterial growths, 
and have found that the bacterial growth in the medium seems 
to be entirely limited to zones which are probably foramina of the 
tooth, chiefly apical with some lateral. I have similarly tested 
this same problem by placing within the teeth, solutions, the ions 
of which, when they would pass by osmosis from the tooth to the 



198 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

agar media surrounding the tooth, would react on the coloring 
medium by the change in the pH. These have also indicated that 
for all practical purposes a very large proportion of the total com- 
munication is limited to the foramina. In Chapter 23 we 
have shown that the structure forming the boundary between 
dentin and cementum, is in effect a dialyzing membrane, and that 
electrolytes may pass through that membrane quite freely while 
colloids cannot. It is, accordingly, very probable that certain 
crystalloid substances can pass through this boundary. 

SUMMARY AND CONCLUSIONS. 

It should be remembered that in the formation of the tooth, 
both the dentin and cementum are built upon a first zone of calci- 
fication which is in effect a continuous fire-wall or protecting 
zone between the two structures, with but relatively few direct 
connections or openings from the dentin to the cementum. In 
the structure of the dentin, with its long and narrow channels 
constituting the dental tubuli with their anastomosing branch- 
ings, we have a structure, particularly favorable, for the hiding 
away of the organisms because of the mechanical difficulty of 
getting medicament into the structure. We think it is probable 
that often a relatively high efficiency may be secured in sterilizing 
young dentin to the granular layer, and possibly to the dento- 
cemental junction. We think it is very improbable, from our 
many experiments, that the cementum can ever be sterilized by 
a medicament placed within the pulp chamber, without definitely 
and seriously embarrassing the surrounding supporting struc- 
tures. 

We would, therefore, change the accepted fundamental from 
That injected teeth can be sterilized readily by medication, and 
that the usual medications do not injure the supporting structures, to 
That infected teeth can be sterilized in the mouth 
only with very great difficulty or by using over 
strong medicaments; and the usual medications 
(particularly those previously used) frequently, if 
not generally, injure to some extent the supporting 
structures. 



CHAPTER XV. 

ROOT FILLINGS, THEIR CONSTANCY AND 
EFFICIENCY 

PROBLEM: Do root fillings fill root canals, and do they 

continue to do so? 

Practically all diagnosticians, whether dental, medical, or 
otherwise, who look at roentgenograms of the teeth, look to see 
whether there is evidence of more or less bone destruction at the 
apex, and if so, whether the tooth carries a root filling. If it does 
not, it is like a bottle filled with infection; if it carries a root fill- 
ing, there is no opening in the bottle, provided the root filling goes 
to the apex. What could be more simple, complete, and fortu- 
nate? 

This particular study was undertaken to establish some of the 
mechanical problems involved: First, under what conditions is it 
mechanically possible to fill pulp chambers? Second, what is the 
constancy of the physical state of the mechanical plug we insert? 
And third, what are the physical properties of the materials used 
for root fillings? 

My work on the physical properties of the waxes, used for im- 
pressions and patterns for prosthetic and inlay work, revealed the 
following important factors: First, that most waxes have 
a wide range of variation in volume in proportion to their 
temperature; and second, that practically all waxes have 
a property of elasticity. Every person who has poured 
paraffin, tallow, lard, beeswax, or such substance when liquid 
and molten with heat, into receptacles to cool, has observed 
that, on cooling the center became depressed and, finally, with the 
last cooling, a great open crater ran down into the mass of the 
material, often to the bottom of the vessel, with branchings in 
various directions. At this stage, 5 to 10 per cent more material 
could be poured into the form filling these cracks before bringing 
it to the original level of the molten mass; and when this mass 
cooled, it again, in the same proportion, had its shrinkage, and so 
on indefinitely. Fundamentally, with a change of state, there was 
a definite change in mass. 

7 See bibliography 

199 



200 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

Since heat was formerly used a great deal in packing gutta- 
percha root canal points, the problem arises, "To what extent 
does the same factor obtain?" All who had experience in the use 
of chloropercha, as it was used so extensively years ago for root 
fillings preliminary to placing the points, had a practical demon- 
stration of the effect of leaving the stopper out of the bottle, with 
the result that the bottle containing, say a half ounce of creamy 
chloropercha would, after evaporation of chloroform, leave a nug- 
get that was always drawn away from the sides of the bottle, 
and which would rattle about with great freedom. In discus- 
sions and questionings regarding the possibilities of this condi- 
tion's obtaining in the mouth, I was always assured that the two 
conditions were not comparable. 

For references to some of the detailed work that I published on 
the relation of change of state to mass, of various substances in- 
cluding molten gold, I would give the following: Price 8 — The 
Laws Determining the Behavior of Gold in Fusing and Cast- 
ing — Dental Cosmos March 1911; Special Researches in Phy- 
sics — Journal of the National Dental Association, October, 1914; 
and the reference to my previous publication on this subject in 
the Journal of the National Dental Association, December, 1918. 





Figure 108. Two similar wax bars placed in a warm investment 

AND CAST. A, BEFORE HEATING, B AFTER HEATING AND WHILE INVESTMENT 
WAS STILL SOFT, SHOWING THE CHANGES IN THE WAX AND THE SHAPE OF THE 
CASTING. 

From the latter I take the following illustration. Figure 108 
shows similar wax bars placed in a warm investment and cast: 
A, in wax before heating by putting in the warm investment; and 

8 See bibliography. 



CHAP.X\ ROOT FILLINGS, rHEIR CONSTANCY AND EFFICIENCY 

B, after casting showing the change that has taken place as a 

result of the heat. This is neither expansion nor contraction; it 
is the releasing Of elasticity. A wax bar was warmed, and while 
sufficiently warmed to compress, the pencil o! wax was put under 
pressure on end. which shortened it. In changed state under 
pressure it was chilled. Another cylinder of the same wax was 
treated similarly, except that it was stretched instead of con- 
densed. From each, sections one inch long were taken. These 
two wax bars were similar in every respect, except that one had 
a retained elasticity in one direction, and the other in the opposite 
direction. When the two pieces of wax were placed in the warm 
investment, the warmth released the retained elastic stress; and 
after the retained elasticity was released, the compressed piece 
became longer and the stretched piece became shorter. This took 
place in the investment which was heated just enough to follow 
the changing wax, with the effect that before the wax was melted 
from the investment, two entirely different sizes of molds had 
been formed. Since both were attached to the same sprue-gate, 
and both were cast together, the castings reproduced this physical 
change which took place in the wax. It also followed its own law 
of contraction, and all diameters were reduced in accordance with 
its laws of contraction. 

In the former of the articles just referred to, I showed that pure 
gold changed approximately 2 per cent in mass, within a fraction 
of a degree, in changing from the solid to the liquid state, and ap- 
proximately another 2 per cent in changing from its first crystal- 
line form as it freezes to room temperature. These are cubic 
measurements, linear being one-third of this amount. Ice be- 
haves differently by changing in the opposite direction, which is 
the reason pipes and bottles burst. Our waxes, gutta-percha, 
etc., when placed in root canals, behave in the opposite manner to 
that which water does when taking on the solid state, and change 
to a greater degree, ice being 11 per cent greater in volume than 
water at the freezing point. To test these dimension changes 
cylinders of glass were used, and the gutta-percha packed with 
all pressure the cylinders would stand at various temperatures, 
and these, when cooled, were tested for the filling of the chambers 
by placing ink in the cylinders, which invariably passed in be- 
tween the gutta-percha and the cylinder walls; and, indeed, it 
was a physical impossibility so to pack the gutta-percha at a tem- 
perature at which it could be molded, that there would not be a 
space between the gutta-percha and glass when the gutta-percha 



202 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

had cooled. Several hundred pounds' pressure were used on the 
gutta-percha without avail, and, notwithstanding that the pres- 
sure was kept on the gutta-percha while it was cooling (which 
could not be done in a tooth) , this shrinkage took place. Figure 109 
shows a typical tube demonstrating this effect. The metal pis- 
tons are shown continuing the pressure of several hundred 
pounds on the gutta-percha, notwithstanding which, the gutta- 
percha left the glass sufficiently to let the ink flow between. 




Figure 109. Gutta-percha under a high pressure inside of glass 
tubing, to test the shrinkage of cooling gutta-percha. note the 
ink flowed freely into the shrinkage space. 

However, it is not considered feasible to make gutta-percha 
moldable in root-filling procedures by means of increasing its 
temperature. This is done by placing it in a solvent, usually 
chloroform or chloroform carrying rosin, and the use of oil of 
eucalyptol as a solvent. Gutta-percha dissolved in chloroform 
to a consistency of a thick cream or paste, has a volume 300 per 
cent greater than that of the original material; or to express it 
otherwise, if the pulp chamber is filled with gutta-percha at about 
that consistency, when the chloroform has evaporated from it, 
the chamber would be approximately one-third full. If we put 
into the creamy mass a cone of dense gutta-percha, the usual gut- 
ta-percha point used in root filling, and select one which fills the 
chamber within 90 per cent of full, leaving only 10 per cent of the 
volume for the chloropercha, the chamber will still lack 6.6 per 
cent of being full, when the chloroform has volatilized. Doubt- 
less, many operators have supposed that, merely softening the 
point with chloroform to make it flexible and moldable, would not 
change its volume, which is not correct. A sufficient quantity of 
chloroform to make the gutta-percha flexible is sufficient to 
change its mass very definitely as will be shown. Gutta-percha, 
when dissolved with chloroform, makes a sticky paint; but when 
thechloroform is gone, it peels from all smooth surfaces in its 
process of contraction and does not retain adhesiveness. It was 
doubtless for this reason that Dr. Callahan sought another sub- 



CHAP. X\ ROOT FILLINGS, THEIR CONSTANCY IND EFFICIENCY 

stance, suggested and used rosin; and doubtless for this 

reason, and tor the advantage of a non-irritating sterilizing 
medium that Dr. Buckley suggested eucalyptol as the solvent for 
gutta-percha. The ultimate contraction is very great tor both 

Of those substances, and corresponds ultimately, relatively with 
the amount of solvent used, whether the solvent be chloroform, 
eucalyptol, or chloroform carrying rosin. 

The gutta-percha in oil of eucalyptol, the eucapercha of the 
market, has a volume 117' | greater than the volume of the gutta- 
percha alone, which means that a pulp chamber, filled with euca- 
percha and submitted to long and complete drying, would ulti- 
mately have 24 r ( of the total volume of the pulp chamber filled. 
When it solidifies, it does so into a lumpy, curdled mass which 
does not adhere to smooth surfaces. It, however, very fortunate- 
ly, undergoes this drying process slowly. After weeks of sponta- 
neous air drying at room temperature, it reduced to 87 ( " ( of the 
original volume. During a similar period, gutta-percha and 
chloroform would have diminished to 76^ of the original volume. 
However, by the addition of artificial heat equivalent to that fur- 
nished by the body, the rate is greatly hastened, as shown by the 
tables; but it is not hastened by moisture. 

Rosin and chloroform mixture also undergoes a very great re- 
duction in volume, starting with a fluid about the consistency of 
a light oil. Dr. Callahan suggested a consistency of sewing ma- 
chine oil as best. In this condition it has a volume 4069? of that 
of the volume of rosin. In other words, a pulp chamber filled 
with rosin and chloroform solution of that consistency would 
ultimately be about 24.6 r c filled. Again, using gutta-percha 
cones to occupy, say 90 r ( of the total volume, would ultimately 
leave approximately 7.5 r ( of the pulp chamber unfilled when the 
complete drying out process has occurred. How r ever, the gutta- 
percha point will rapidly take up the chloroform and swell so that 
it will occupy more space, readily swelling to increase in volume 
14 to 54 in the softening process. Since the pulp chamber can con- 
tain only a given amount of material, whether fluid, semifluid, or 
solid, it is a physical impossibility to put in material to make up 
for the evaporation of the solvent, while the solvent is present. 
"It is, therefore, a physical impossibility completely to fill a pulp 
chamber with gutta-percha made plastic by any of the above sol- 
vents, except at the time the gutta-percha contains the solvent." 

The chloroform and rosin compound has very distinct and 



204 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

favorable qualities, in that it is very adherent and tenacious in 
all stages, to both smooth and rough surfaces. In this respect, it 
is unlike each of the preceding compounds. The result of this 
quality is that, when a root filling is made of this material and 
gutta-percha cones, the contraction tends to express itself in a 
large part, by a shrinking towards the walls if dry, rather 
than as a continuous disc at the side of the mass, and between it 
and the wall, and herein lies the great virtue of this material as a 
means for filling pulp chambers. 

It will be a matter of surprise, doubtless, to most of us to find 
that a skin is formed on the surface of each chloropercha, and 
rosin and chloroform, particularly the latter, which quite effectu- 
ally delays the drying-out process. In a case of the chloroform 
and gutta-percha in a narrow chamber, this skin or film separates 
from the vessel or container, leaving a fault, which ultimately 
makes a series of caverns, each projecting from the last until the 
entire mass is honey-combed. In large chambers it contracts to 
a central free mass. Chloroform and resin in a narrow chamber 
of the same form retains the continuity of the protecting surface 
skin by its adhesion to the wall, and underneath this film the 
liquid retains a fluidity nearly that of the original, due to the con- 
trol of the vapor tension by this membrane. Consequently, it is 
not only a matter of weeks, but of many months, before our root 
fillings, inserted with any of these three compounds, will have 
attained their maximum contraction. After air drying in an open 
vessel for two weeks, rosin-chloroform had reduced to 65% of its 
original volume ; in five weeks to 59% ; eight weeks to 36.4% , and 
the last 12% of the total shrinkage requiring either a long period 
of time or the addition of artificial heat nearly to the boiling 
point of water for many hours. When we consider the great 
variety of forms of pulp canals and the variations in size, shape, 
and direction of the many foramina, it is evident that the root 
filling material must seal these foramina by a process of retreating 
while retaining a close adhesion to the surface of the foramen, 
instead of contracting to a common center of the mass, producing 
a fault or space. An illustration of some of the difficulties en- 
countered in root canal fillings is shown in Figure 1 10. Many other 
cases are shown throughout this volume, as for example, in the 
following conditions: 

It will clearly be seen that there are many conditions which 
would make impossible the placing of a large percentage of gutta- 



J 



CHAP w ROOT FILLINGS, THEIR CONSTANCY IND EFFICIENCY 




Figure 110. Shows the multiple foramina, branchings, enlargements, 
and constrictions in the root apex. 

percha in the root filling, because of physical conditions: for ex- 
ample, in fan and wedge-shaped canals. No gutta-percha points 
are made fan-shaped. They are conical. Nor are they made 
wedge-shaped. The balance of the chamber, that cannot be 
filled with one or more of the conical points, will be filled with the 
solvent used ; and in case of a lateral canal or several of them, it 
would clearly be impossible to work the hard gutta-percha into a 
cross canal, and particularly to make it fill the enlarged opening 
which many of the foramina have in the cementum. 

In general, it may be stated that the amount of ultimate con- 
traction will be the amount of solvent present, assuming that the 
pulp chamber was filled completely with the root filling and its 



206 DENTAL INFECTIONS, ORAL AND SYSTEMIC—RESEARCHES— VOL. I 

solvent. The problem of the content of dentinal tubuli will be 
taken up in a subsequent chapter. 

A large number of studies have been made of our own efforts at 
root-filling, to determine whether or not we had succeeded in fill- 
ing the roots, and whether sterile teeth, when filled by us under 
ideal conditions outside the mouth, would remain sterile if placed 
in an infected culture medium ; and in most instances, organisms 
were found in the tooth structure, in or beside, the root-filling 
material, or both, in a few weeks' time, and practically always 
after a period of a few months. Some of these studies are re- 
ported in detail in one of my articles referred to above. To 
assist me in this work, I engaged the service of Dr. Dayton C. 
Miller, Professor of Science, Case School of Applied Science, who 
made volumetric tests with a high degree of accuracy. The fol- 
lowing are Dr. Miller's general remarks: 

"The first noticeable fact in the experiments was the extreme 
slowness with which evaporation proceeded under spontaneous 
air drying. It would have required a year, or more, for the ma- 
terials in the jar to have solidified. Even when heat of 70° C. 
(169° F.) was applied, the process was not much accelerated. A 
temperature of boiling water was required, and this was sufficient 
to melt the rosin and to soften the solid gutta-percha. 

"It is not improbable that the rate of drying in a tooth cavity, 
the walls of which are more or less porous, would be different from 
that in a glass jar. It is possible that the body fluids may affect 
the rate; but experiments show that the placing of the material 
in water does not assist hardening, but rather prevents it. 

"A conspicuous physical property of the materials is the great 
contraction in volume, the final volume in one instance being less 
than a fourth of the original volume. 

"Both of the gutta-percha materials not only contract in vol- 
ume, but in doing so they fail to adhere to the surface of the jar, 
leaving it clear of protecting covering, and the materials become 
porous or granular in structure. It would seem that these prop- 
erties would render the materials useless for the filling of root 
cavities. As an illustration it may be assumed that root canals 
have diameters varying from 0.001 inch to 0.015 inch, that is 
from 0.025 millimeters to 0.375 millimeters, and that bacteria 
may have a size varying from 0.0005 mm. to 0.005 mm. The pos- 
sible contraction of fluid gutta-percha root-filling material in the 
smallest root canal may be 0.005 mm. while for a large canal it 




Figure 111. R(xrr canal filling shrinkage. A as roentgenographed 

IN TIIK MOUTH, B AFTER EXTRACTION, C A CROSS SECTION OF THE TOOTH AND 
ROOT FILL INC. 

may be over 0.075 mm. ; these contractions are much larger than 
the sizes of bacteria. While these statements of the contractions 
are not exact because of the uncertainties in the manner of dry- 
ing, yet it is certain that there will be little protection against the 
entrance of bacteria. 

"The rosin solution when drying differs from the other in that 
a solid coating remains tenaciously adherent to the whole inner 
surface from which the fluid has receded, and the solid does not 
at any time part from the walls. Thus the whole inner surface 
of the cavity remains protected, and no cracks are left where 
bacteria may enter through the small canal. There is an inner 
hollow space, but it is wholly surrounded by the painted walls, 
and closed at the bottom by the solid. 

"These conclusions, however, are not final in regard to the filling 
of teeth for the conditions in a living tooth are certainly different 
from those in the glass jar. But the facts of physical contrac- 
tions, etc., are exactly the same in the two cases." 

It is clearly evident also, from the clinical data available, that 
root canal fillings do not continue to fill the roots of teeth with as 
high a degree of efficiency, as is generally supposed. Figure 111 
shows one of these root fillings, which in the original roentgeno- 

207 



208 DENTAL INFECTIONS. ORAL AND SYSTEMIC—RESEARCHES— VOL I 

gram of the tooth in the mouth, gave the appearance of filling the 
canal. A shows a roentgenogram of the tooth in the mouth; B, 
a roentgenogram of the tooth after extraction, showing the mesio- 
distal appearance which, of course, could not be taken in the 
mouth ; and C, a cross-section of the tooth above the branching. 

These studies of the underlying fundamentals indicate how 
much more difficult it is to fill root canals mechanically than is 
generally supposed. If, however, a tooth is root-filled, which is 
surrounded by a non-infected vital membrane throughout its 
entire cementum, it will doubtless be very difficult for organisms 
to enter even unfilled dental tubuli, provided they are thoroughly 
sealed, if such is actually accomplished with chloroform and rosin 
at the pulpal end of the tubule. If, however, the dentin about the 
apex is denuded and infected as part of the apical and pulpal in- 
volvement, it will doubtless be more readily possible for that in- 
infection to gain entrance to, and infect, the dentin because of 
the continuous anastomosis. It is accordingly probable that 
favorable teeth, whose dentin is infected, but whose cementum 
is not infected, and has normal attachment, may have from 
ninety to ninety-nine per cent, possibly more, of the organisms 
destroyed by medication with Chloramin-T without consider- 
able injury to the supporting structures, and that such teeth can, 
under most favorable conditions — namely, direct access, a round 
canal without islands, bays, or fan-shaped channels — be filled 
so that the great majority of the tubuli are sealed at their pulpal 
ends and the pulp chamber filled to within a few per cent of full 
the first few weeks, a larger per cent of unfilled space developing 
with the succeeding months with an ultimate space in even the 
most favorable root fillings adequate for the housing of many 
millions of bacteria, which, if they may find access to such an 
area, will be sufficient in quantity to do definite damage to the 
host, provided that individual's defensive activity against that 
organism is not sufficiently high, a matter which will be discussed 
in detail in subsequent chapters. 

In the preceding chapter under the discussion of the efficiency 
of medication I have reported the result of planting the roots of a 
tooth beneath the skin of a rabbit, which had been as thoroughly 
root-filled as an unusually skilled operator was capable of doing 
after treating the teeth by a process which is proven to be as 
efficient as any we have available. The placing of these supposed- 
ly sterile teeth, which presumably could not because of their root 



CHAP w ROOT FILLINGS, THEIR CONSTANCY \ND EFFICIENCY 

fillings again become infected, underneath the skin of the rabbits, 
produced results which indicate that they were not Sterile, and 
were not free from toxic irritation. That this was true, was fur- 
ther demonstrated by drilling into these roots and culturing after 
sterilizing the surface. 

As a part of the daily routine of our research, extracted teeth, 
which are suspected of being related to systemic conditions, are 
cultured, some by crushing the root tip or the whole tooth, many 
by sterilizing the surface and drilling into the tooth structure 
with a sterile drill and culturing the chips, some by sterilizing the 
external surface and culturing the tooth. Of the last thousand 
teeth, less than one-tenth of one per cent of all of our root-filled 
teeth so tested, failed to grow a culture of streptococci. 

SUMMARY AND CONCLUSIONS. 

When we consider how many thousands of the extracted teeth 
we have cultured and found to be infected within the tooth struc- 
ture, and the extremely low percentage, practically zero, in which 
infection was not demonstrated, together with the fact, that so 
many teeth with excellent root fillings, show structural changes 
of the supporting tissues after a few years have elapsed, we are 
led to believe that we are dealing in these cases with one of the 
clinical expressions of the physical facts we have just been study- 
ing. 

We are, therefore, though very reluctantly, compelled to 
change our original premise which provided that, good root 
fillings fill pulp chambers and continue to do so indefinitely, to 
the following: 

Root fillings rarely fill pulp canals sufficiently 
perfectly to shut out bacteria completely. Root 
fillings usually fill the pulp canal much less perfect- 
ly some time after the operation, than at the time 
of the operation, due to the contraction of the root- 
filling material. The ultimate volume contraction 
of the root filling is approximately the amount of 
solvent used where a solvent is used with gutta- 
percha as a root-filling material. 

(Note:) It is not proven that it is absolutely necessary that 
teeth be perfectly sterilized or that they be perfectly root-filled 
in order that an individual may not develop systemic involve- 
ment, since under favorable conditions the patient may provide 
an adequate defense or quarantine against these materials. 



CHAPTER XVI. 
COMFORT AND SERVICEABILITY AS SYMPTOMS. 

PROBLEM: Are local comfort and efficiency of treated 
teeth an evidence and measure of the success of an operation? 

EXPERIMENTAL AND DISCUSSION. 

Clinical diagnosis as a science is based upon symptomatology. 
If we were to ask the question of the dentists, oral surgeons, and 
physicians of the country, the great majority would give the 
affirmative answer to the above question; as would also nearly 
100 per cent of the laity. The special research on this problem has 
been undertaken to determine the relationships between symp- 
tomatology, clinical pathology, and tissue pathology. The ap- 
proach has been made in three ways: First, by comparing the 
history and symptoms with the presence or absence of evidence 
of systemic involvement; second, by comparing the history with 
the local histopathology ; and third, by tabulating a large number 
of cases to determine the type of condition which, when oblit- 
erated, produced a change in systemic reaction, including both 
the groups of disturbances with and without evidences of local 
discomfort. 




Figure 112. Infected laterals which have given frequent and severe discomfort. 

Figure 112 shows roentgenograms of teeth of individuals that 
reported either continual or frequently recurring tenderness of 
the teeth here shown. The lateral in A has been crowned for 
some years, with recurring acute tenderness and finally with a 

210 



CHAP. XV] C0MF0R1 WD SERVICEABILITY VS SYMPTOMS 211 

violent abscess which produced extreme discomfort and swelling. 

B shows a similar lateral which has a partial root filling, as has 
also the cuspid. The lateral has had recurring apical abscesses 
developing for a long period, the tooth becoming very severely 
inflamed with each recurrence. 




Figure 113. Teeth formerly with fistulae and recurring tenderness, latterly 
comfortable. all badly infected. 

In Figure 113, we have roentgenograms of the teeth of a group 
of cases with the following history : For a more or less extended 
period of time these teeth were, on recurring occasions, tender or 
had what the patients termed gum boils. Sometimes this chang- 
ing condition extended over a period of years, and finally the 
teeth ceased to become tender. In A the tooth had a fistula 
which wculd occasionally close; the tooth would become tender; 
the fistula would open, establishing free discharge into the 
mouth; and the tenderness would subside. We insisted upon the 
removal of this tooth. The patient always delayed the operation 
and finally stayed away a couple of years for fear we would carry 
out the program. Finally the fistula closed; the tooth ceased to 
become tender; and the area of absorption became smaller as 






212 DENTAL INFECTIONS, ORAL AND SYSTEM IC^RESEARCHES— VOL. I 

shown in B. The patient began to develop symptoms of rheu- 
matism and consented to its removal. The rheumatic symptoms 
were relieved. 

Figure 113-C shows a lower right second molar rilled many years 
ago, and previous to about three years ago very frequently gave 
the patient trouble, with tenderness and some swelling. About 
that time she contracted "Flu" which was complicated with a 
lung involvement and also with a heart involvement, which 
latter kept her in bed for most of a year, and she was an invalid 
for a year and one-half. During the time of her attack with 
"Flu" and the subsequent lung and heart complications, and 
also since these latter had subsided, since she had had no tender- 
ness whatever in this tooth, she had come to the conclusion that 
there was no need for its extraction, a matter in which her dentist 
concurred notwithstanding he had a roentgenogram and knew 
the history. 

In another chapter (Chapter 60) I discuss the relationship 
between the susceptibility to heart which this lady inherited, five 
of the relatives on the father's side, including her father, having 
died in middle life with heart involvement; and in the chapter 01. 
the relation of condensing and rarefying osteitis, I have discussed 
the significance of the zone of condensation, which appears in 
this roentgenogram, and its relation to this clinical history. (Lo- 
cal Structural Changes. Condensing around Rarefying). The 
facts are very clear, that during the period when this tooth was 
giving serious and frequent local disturbance, the patient was 
relatively more safe, than in the later period during which it gave 
no response and was for all intents and purposes a normal tooth. 
The reason for this is discussed in the chapter on the nature and 
significance of local reaction. 

In Figure 1 14 we have a group of crowned centrals showing even 
greater areas of pulp canal unfilled, which, according to the his- 
tory, have never been uncomfortable, and the patients were able 
to eat with them without thought or consideration. A presents 
the roentgenographic appearance of the teeth of a middle aged 
man who was suffering so acutely from rheumatism that for 
months he had walked with great difficulty, besides which he was 
suffering severely and was almost incapacitated from his work. 
With the removal of these teeth, his symptoms were completely 
relieved and have not returned for five years. He states that 
he would not have them back for a million dollars. (Incidentally, 



CHAP. XVI C0MF0R1 SND SERVICEABILITY ^S SYMPTOMS 213 




Figure 11 1. Infected teeth with no history of discomfort. 

it is of interest to note that the patient reported that his former 
dentist, following the regulation basis of interpretation, insisted 
that these teeth could not be related to his condition without show- 
ing more evidence of involvement. He also stated that he 
would eat his own hat if the man were any better after their re- 
moval. I have not learned whether he has yet done so but the 
patient insists that this is his treat.) The significant thing about 
this patient's teeth in connection with this present study is that 
they never were in the slightest tender and he had no suggestion 
or indication of an abnormality or infection. 

Figure 114-B shows the teeth of a young lady suffering very 
severely from rheumatism and heart involvement with no local 
symptom of tenderness about these teeth, but which were in- 
fected, and after their removal with some others her symptoms 
so completely disappeared that she was able again to work, which 
she had not been able to do for many months, and in five years 
has had no recurrence. These two patients belong to the group 
of strongly inherited susceptibility. On the basis of comfort there 
was no suggestion whatever that these teeth were not in perfectly 
safe condition, notwithstanding the lateral contained a putrescent 
pulp of long standing. 

These three groups of illustrations cannot be considered as 
proving anything since they represent such a few cases. How- 
ever, they are selected simply as typical of large groups, and, 
therefore, are significant as typical illustrations. Those in Figure 
112 are all classed in the non-susceptible group; those in Figure 
113, the acquired group; and those in Figure 114, the strongly 
inherited group. 



214 DENTAL INFECTIONS ORAL AND SYSTEMIC—RESEARCHES— VOL. I 
SUMMARY AND CONCLUSIONS. 

An analysis of these four groups of studies suggests to us the 
following : That there is a direct relationship between the extent 
of rarefaction or absorption about roots and the condition 
of comfort; that this condition of absorption is directly related to 
the recurring acute inflammatory processes; and conversely, that 
the absence of extensive areas of absorption accompanies cases 
without a history of recurring acute processes, and that these 
two conditions are not directly related in the order of the extent 
of the absorption to the condition of systemic involvement, but 
inversely so; for with a given infection, the patients, with a large 
area of absorption and a history of recurring tenderness of the 
tooth, have been free from systemic involvements; and those with 
relatively small areas of absorption in proportion to the capacity 
of the tooth for infection, have proven to be the patients with 
systemic involvement. We shall give our interpretation of these 
phenomena in Chapters 45 to 56. 

We would, therefore, reverse the accepted fundamental that 
comfort and serviceability are criteria of the success of an opera- 
tion or the dangerousness of a tooth to the safety of a patient to 
the following: 

Local comfort not only is not a certain index of 
success or safety but constitutes both what is prob- 
ably the greatest paradox and the costliest mistake 
through loss of health and life that exists in both 
dental and medical practice, because it may only 
mean the absence of local reaction which would, if 
present, incidentally make the tooth sore and fun- 
damentally destroy the infection at its source; 
whereas, the absence of this local reaction and its 
consequent destruction of the infection products 
permits them to pass throughout the body to irri- 
tate and break down that patient's most susceptible 
tissue, which tissue can be anticipated very fre- 
quently. 



CHAPTER XVII. 
QUANTITY. SYSTEMIC EFFECT, AND TOOTH 
CAPACITY. 

PROBLEM: What is the relationship of the quantity of 
dental infection to the type and extent of systemic 
involvement? 

EXPERIMENTAL AND DISCUSSION. 

That the problem of systemic involvement is essentially the 
problem of the overwhelming of the natural defenses by a large 
quantity of dental infection, is a fundamental that seems to be 
quite universal in its general acceptance. While it is recognized 
that there is a great difference in the virulence of organisms from 
various sources, since the capacity of a tooth is so small it is not 
deemed possible that a properly root-filled tooth will have capac- 
ity enough for sufficient dental infection to overwhelm the pa- 
tient; and furthermore, the organisms constituting dental infec- 
tions have been reported by so many writers to be of so low viru- 
lence, that the professional mind has come to accept that a funda- 
mental requisite for a tooth to be a source of serious involvement 
will be that there is present, in addition to the infection in the 
tooth, a quantity of infection in what is considered an abscess or 
pus sac at the root apex, and which, because of its capacity, 
comes to be a menace and possible danger. Howe states in his 
article "The Focal Theory of Infection in its Application to the 
Teeth" the following: 

"In the experimental work that is used to support this theory, 
young animals, intravenous injections, and massive doses are 
used. It is replied to the criticisms that these doses are excessive 
and do not fairly represent what occurs in the human body, that, 
at times, it is possible to produce the desired pathological effect 
with smaller doses. These doses range from what in the case of 
man of 70 kilos, or 154 lbs. would be from ten quarts to a cupful. 
What is termed a small dose is one or two cupfuls of microorgan- 
isms in the case of a man of 154 lbs. Pure cultures are not 

" See bibliography. 

215 



216 DENTAL INFECTIONS. ORAL AND SYSTEMIC -RESEARCHES— VOL. I 



injected. The granuloma, the abscess, or pyorrheal pus, and the 
pulp are dropped bodily into ascetic-dextrose broth, allowed to 
grow, and the broth containing the conglomerate mixture of 
bacteria, altered and decomposing tissue and its morbid products 

are injected en masse into animals Now we do not often 

deal with doses ranging from a cupful to five or six quarts from 
dental sources. Yet, to produce such results as are described, 
they must be used. In the small dose of a cupful of microorgan- 
isms, together with the other putrefactive products mentioned, 

possibly or occasionally an effect is obtained Others have 

inoculated rabbits with ten to fifteen c.c. doses of streptococci of 
this type for three months and nothing has happened." 

These researches have been conducted to ascertain what the 
quantity of dental infection may be in various cases, and how 
much of it may be sufficient to produce systemic involvement, 
and what may be the capacity of a tooth even with a good root 
filling as a reservoir or bacterial and toxin generator. Our first 
problem has been to determine the capacity of the tooth. To do 
this, we have taken freshly extracted, root-filled teeth, removed 
all excess moisture, and weighed them. We have extracted the 
moisture by placing them in a chamber in which the moisture of 
the air was being extracted by such chemicals as sulphuric acid, 
none of which came in contact with the tooth. The teeth were 
again weighed, re-soaked in water, weighed, and again re-dehy- 
drated without carrying the dehydration to the point of removing 
water of crystallization. Figure 115 shows a group of such teeth ; 
and it is found, in general, that approximately 5% of the volume 
of every root-filled tooth is a fluid which may be a culture medium 
and may be abundantly saturated with bacteria. 

CHANGE IN WEIGHT OF TOOTH STRUCTURE 



Fresh 
Tooth 


Dehydration 


CaCl 2 
M 


H 2 

0.5770 

0.7424 


Net 
Gain 

/o 


Net 
Loss 

% 


Weight 
Before 


Weight 

After 


0.00706 
0.9188 


No. I 


0.9940 
0.6124 


0.8910 
5801 


302% 
1.33 


1.56 

1 01 


No. II 


1.0372 

0.8635 


0.9280 
. 7500 


0.9280 



Figure 115. 





; 







Figure 116. Dental caries extending along the tubuli toward the pulp, upper 
is cavity end of tubuli, lower near pulp. 

217 



218 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

Figure 116 shows the organisms stained directly in the tubuli of 
the teeth. Many of the earliest efforts to stain bacteria within 
dental tubuli were confused by the photographing of the abrasive 
in the tubuli, which, with modern methods of staining, can be 
readily differentiated from bacteria; and besides, the tissue in 
Figure 116 was not ground but was decalcified, and there was no 
opportunity for foreign substances to contaminate the tissue. 

The capacity of the pulp chamber for infection maybe more or 
less than that of the total of the dentinal tubuli and acini and 
canaliculi of the cementum. However, with a large and open 
root apex, the content of the pulp chamber can be emptied into 
the tissue without destruction of a large area, and hence with 
greater concentration than from the dentin. In the construction 
of the tooth with the laying down of dentin and cementum in 
juxtaposition, there is established what is, in general effect, a 
fire-wall between these two structures, which, while it has many 
small openings uniting these two and a few larger ones, as multi- 
ple foramina and accessory canals, impedes the passage from the 
dentin to the patient of the infection and toxic substances in 
large amounts. 




Figure 117. Acute endocarditis, with extensive vegetation on valve cusp, 
produced in a rabbit's heart by the intravenous injection of the organisms 
washed from a single root-filled tooth. these organisms weighed approximately 
one millionth part of a gram. 

Another phase of this study has included the injection into 
experimental animals of the organisms that could be washed 
from a single root-filled tooth. Figure 117 is typical. It shows the 
heart of a rabbit which has developed acute endocarditis from the 
injection into the rabbit of the settled washings of the crushings 



CHAP w 11 Ql VNTITY, SYSTEMIC EFFECT. AND TOOTH CAPACITY 'J.VJ 

of the t(H)th of a patient suffering from acute endocarditis. The 
weight of the organisms injected into this rabbit was determined 
by counting the number present in a known dilution and. by cal- 
culation, establishing the total number approximately, which was 
found to be a millionth part of a gram. 

To answer the question whether there are possibilities of other 
substances than organisms having been taken from the teeth 
which produced these disturbances, we have made a large series 
of studies to ascertain whether toxic substances other than or- 
ganisms are present in teeth. This we will study in the next 
chapter. We have also centrifuged the organisms, removed the 
Quid, and resuspended them in normal salt solution and inocu- 
lated them into rabbits, and have produced lesions and death of 
animals. 

An analysis of several hundred individuals from whom teeth 
were removed having root fillings without evidence of periapical 
chambers containing infected granulomata, discloses that in a 
large number there has been a very marked, if not complete, 
relief of the systemic expression upon the removal of the tooth in 
question. 

To determine whether or not a quantity of infection must be 
injected into a rabbit which would be equivalent to a "tea-cupful 
or several quarts per man" I made the following experiment: 
Into many dozens of rabbits we have planted beneath the skin a 
freshly extracted tcoth to determine what the effect would be of 
the small amount of infection that a single tooth could contain. 
These have revealed a very great difference in the virulence of 
different strains and the type of reaction they would produce. 
In the chapter on kidney involvements we show- several cases in 
which the planted tooth produced nephritis in the rabbit without 
the development of an extensive abscess about the implanted 
tooth, and in some cases the same tooth transferred to another 
rabbit again produced kidney involvements. In many cases the 
teeth become incysted. Many of these are discussed in subse- 
quent chapters. Still others produce wasting diseases and the 
rabbit slowly fails in weight and finally dies. Others produce 
most violent toxic and bacterial reactions, causing the death of 
the rabbits in from a few days to a few weeks. 

Figure 118 shows a roentgenogram and photograph of a tooth 
extracted from a patient suffering from a severe systemic involve- 
ment of the central nervous system, not suspected to be related 
to her teeth. This is discussed in further detail in Chapter 66. 



220 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




Figure 118. Two views of a molar tooth producing no local discomfort for 

THE PATIENT BUT WHICH KILLED MANY RABBITS IN SUCCESSION, IN AN AVERAGE OF FOUR 
DAYS. 

This tooth was placed under the skins of thirty-one different rab- 
bits, twenty-nine of which died spontaneously in from one and 
one-half to ten days, an average of four days. One of the rabbits 
which lived ten days, received special treatment to increase its 
defense. These all died in general of the same symptoms. An- 
other rabbit (Rabbit 986) of this series was injected intravenously 
with 0.03 cc. of the fluid surrounding the tooth in one of the rab- 
bits. This rabbit was dead in about one and one-half minutes. 
Another (Rabbit 989) was injected with the highly centrifuged 
material, which would not be entirely bacteria-free but nearly so, 
and it was dead in about seven hours. Another (Rabbit 991) was 
injected intradurally with the bacteria-free filtrate of this ma- 
terial and it died within twenty-one hours. The symptoms and 
reactions in the animals are discussed in the chapter on diseases of 
the nervous system, Chapter No. 66. 

In order further to study the relation of quantity, very small 
glass tubes, approximately the size of a fine cambric needle and 
three-quarters of an inch long, were filled with this material. 
These open end tubes were placed inside the needle of a hypoder- 
mic needle and passed under the skin of a rabbit; and as the 
needle was withdrawn, the tubes were placed beneath the skin. 
The quantity of the culture fluid that these needles contained was 
approximately one five-hundredth of a gram each. From one to 
four of these small tubes were placed beneath the skins of rabbits 
and several were used for different types of tests. When placed 
in the peritoneum, Rabbit 1010 lost 585 grams, or 40 per cent of 
its weight. It died in 54 days with extreme muscle atrophy. 



CHAP. XVII QUANTITY. SYSTEMIC EFFEC1 VND TOOTH CAPACITY '1'1\ 

When placed subcutaneously, Rabbit loll lost 160 grams, or 33 
per cent, in 38 days, it died of lobar pneumonia, with congestion 
of the myocardium. Another Rabbit 1012) with a single tube 
placed beneath the skin, died in 5 days, with a loss of 75 grams, or 
7 per cent, with a very large subcutaneous abscess, and hypere- 
mia of the chest and abdominal viscera. 

In order still further to determine this problem, two small 
round cover slips were sealed together with sodium silicate I liquid 
silex) and two very small openings left at opposite sides for the 
organisms to escape. The distance between these cover slips was 
approximately a fortieth of a millimeter. The area of the plane 
of fluid was approximately one square centimeter. Hence this 
quantity was approximately 2.5 milligrams of culture fluid. This 
exceedingly minute quantity of infection was sufficient to kill this 
rabbit in 44 days. I Rabbit 995). 

A further study of this tooth was made to ascertain the relation- 
ship between the size and number of external openings to the 
danger, as evidenced by the length of time required for the tooth 
to kill a rabbit after it was planted beneath the skin. It was 
found, in general, that increasing the number of exits from the 
dentin increased the toxicity of the tooth apparently by giving a 
freer exit to the toxic substances. In this connection I think I 
should state a warning because the need of it has already been 
evidenced. Immature thinking or experience may suggest that 
the transferring of the tooth from one rabbit to another is synony- 
mous and comparable with the animal passage of organisms in- 
jected intravenously or subcutaneously in lethal amounts, the 
result of which is to increase the virulence of the organism as it is 
successively killing the host. In that instance all organisms in- 
jected in subsequent animals are direct descendants of those that 
have lived in the environment of the animal with a lowered re- 
sistance, which animal has furnished the entire culture medium 
for the organisms, and which, because of the quality of adapta- 
tion expressed in Chapter 2, induces the organism to increase its 
aggressive factors. When, however, a tooth is planted beneath 
the skin of a rabbit and kills the rabbit in two days, and the tooth 
is then washed and placed under the skin of another rabbit, the 
organisms in the tooth which are planted in the second rabbit, 
did not grow in the free body fluids of the dying animal but in the 
incased moisture within the approximately three miles of closed 
channels constituting chiefly the dentin, and these organisms 



222 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

have been slightly, if at all, influenced by the presence of the tooth 
beneath the skin of the rabbit, and practically none of which are 
the descendants of those causing the death of the animal, or at 
least producing the infection within the animal's body. The pas- 
sage of a tooth, therefore, from animal to animal is little more 
than changing its incubator and does not constitute animal pas- 
sage in the sense that intravenous injection of a culture is under- 
stood. 

I have, therefore, conducted experiments to obtain data, if pos- 
sible, that would indicate whether it is possible for especially 
vigorous and healthy animals to destroy the virulence of the or- 
ganisms within an infected tooth. There seems no indication 
that even the most vigorous animals have been able to render a 
tooth harmless which had been demonstrated to be capable of 
producing the death of an animal; and while an infected tooth 
when placed beneath the skin of a rabbit, kills small animals in 
proportionally less time than large ones, we have not been able to 
find a rabbit big enough to withstand the toxic substance of cer- 
tain infected teeth. I have discussed elsewhere the circumstance 
of placing such a tooth under the skin of a very large and exceed- 
ingly vigorous buck rabbit, that was a most vicious fighter, seri- 
ously wounding and killing any other male rabbits he could 
reach. On placing such a tooth beneath his skin, in a few hours 
he was sulking in a corner of his cage, and was dead in five days. 

This seems clearly to demonstrate that there is a direct rela- 
tionship between the accessibility of the rabbit or host to the or- 
ganisms confined within the tooth structure, for it seems very 
clear that the dentino-cemental junction seems a very consider- 
able barrier. To determine this we have made the following 
experiment : 

Various chemicals and infected culture media have been sealed 
in the pulp chambers of teeth to ascertain the nature of the sub- 
stances that were capable of penetrating different structures and 
parts of the tooth. As discussed in the previous chapter, when a 
culture of acid producing bacteria is placed in the pulp chamber 
of a tooth, and the tooth planted in a jellied culture medium, car- 
rying a disclosing die, the presence of the organisms can be read 
directly by the color change in the surrounding medium. These 
showed that the organisms leave the tooth only at foramina. 
When, however, chemicals are used containing electrolytes which 
are capable of passing through semipermeable membranes, these 



CHAP XVII QUANTITY, SYSTEMIC EFFEC1 wi> rOOTH CAPACITV 

may pass through the dentin and cementum, or at least appear 
on all surfaces of the cementum as well as the foramina. This was 
also demonstrated by sealing the apex. 



l-'ii.i RE L19. Shows \ smai | ( .i \sv 
11 BE ( UWYING CHIPS FROM w INFECT- 
ED TOOTH. Its size can be judged 

i:\ k OMPAR1SON w 1TI1 THE TOOTH. 




One of these glass tubes containing approximately one milli- 
gram of the drillings of this tooth is shown beside the tooth in 
Figure 119; and one of the tubes which was planted beneath the 
rabbit's skin and open at both ends, containing some of the cul- 
ture media from the organism growing in this tooth had about the 
same capacity, being longer but smaller in diameter. 

When we compute the actual weight of the organisms, not dry 
but moist, which were actually found to be capable of killing some 
of these rabbits, we find it to be approximately one five-hundred- 
thousandth part of a gram. If we allow that a man is twenty 
times as large as a rabbit, which is the usual computation, we have 
a quantity which might be expected to be injurious to man, if not 
seriously so, of one twenty-five-thousandth part of a gram. Or 
when we compute the quantity of this culture medium which 
produced death in these rabbits, approximately one -thousandth 
part of a gram to kill a rabbit in one and one-half days, and ex- 
tending it twenty times that might be expected to be mildly or 
seriously injurious to a man, we find this quantity to be: namely, 
20 cubic millimeters (20 milligrams). This figure does not check 
very closely with Dr. Howe's findings, since a tea-cupful contains 
about 250 grams or 250,000 milligrams. In other words, the dose 
that we have found to be sufficient to kill a rabbit is about 
l/250,000th part of the minimum amount Dr. Howe has sug- 
gested and 1 12,500th part of the minimum amount he has com- 
puted to be necessary to injure a person, using his minimum quan- 
tity of one tea-cupful instead of his maximum, which he states to 
be several quarts. As we have stated above, and as we show 



224 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




Figure 120. Rabbit reactions to open end tubes carrying different substances. 
A, virulent culture; B, same organisms with two per cent phenol; C. normal salt 
solution; D, another dental culture; E, filtrate from culture A; F, SUPERNATANT 

FLUID FROM CENTRIFUGED A. 

in other chapters, many of the teeth that are planted beneath the 
skins of rabbits, produce very little disturbance, while others pro- 
duce very violent disturbance locally and systemically ; and still 
others apparently produce very little disturbance locally where 
planted, but systemically develop nephritis and heart involve- 
ments, as abundantly illustrated elsewhere. 




FIGURE 121. Appearance of a sterile coin two months after implanting be- 
neath A RABBITS SKIN. No FIBROUS CAPSULE FORMATION OR IRRITATION. A SLIGHT 
ETCHING OF THE COIN. 

It doubtless will be argued that these teeth planted under the 
skin of a rabbit, or the glass tubes or any foreign substance, would 
act as a serious irritant and produce local disturbance if not sup- 
puration. To determine this, at the same time as the tubes 
shown in Figure 120 showing the abscess produced by the presence 
of the tube of this culture, similar tubes were planted beneath 
the skin on other parts of the back of this same rabbit. The large 
abscess referred to above is shown at A. At B were planted the 
same organisms but carrying a small quantity of phenol, approxi- 
mately two per cent; at C, similar tubes filled with normal salt 
solution; at D, a similar quantity of the organisms grown from a 
tooth of another patient; at E, tubes containing filtrate of the 
same culture of A; at F, the supernatant fluid from the highly 
centrifuged culture used in A. Serious disturbance was produced 
in the rabbit by only the culture shown at A. (Figure 120). 

As a further test of the result of a foreign irritant, and particu- 
larly that we might study the difference in the structure of the 
tissue which would be organizing about a sterile foreign substance 
and an infected tooth, we planted sterile coins beneath the skin of 

225 



226 DENTAL INFECTIONS, ORAL AND SYSTEMIC -RESEARCHES— VOL. I 



a rabbit and have sectioned the membranes that have developed. 
These are considered in the chapter on the structure of granulo- 
mata, (Chapter No. 38) ; and, incidentally , those experiments reveal 
that even after two months' time a sterile dime, placed beneath 
the skin, has so little tissue organized about it, that, except that 
there is no sign of the skin lesion through which the dime was 
planted, it would seem as though it were planted there but a day 
or two ago, for the inscription on the metal can very readily be 
read through the thickness of this tissue, which is an exceedingly 
thin transparent veil. This is particularly instructive since there 
has been sufficient local reaction to etch the surface of the dime 
and quite largely remove the inscription and lettering. This is 
shown in Figure 121. 

RABBITS WITH SUBDERMAL IMPLANTATIONS 







Sponta- 






Still 
Living 




No. 


neous 


Chloroforn 


Implantations 


In 
Group 


Death 








No. 


% 


No. 


% 


No. 


% 


Subdermal implantations 


237 


181 


77 


30 


12 


26 


11 


Total implantations of teeth 


209 


165 


79 


26 


13 


18 


8 


Sterile coins 


6 


Noloc 


al reac 


tions 








Capillary tubes 


13 


7 


53 


2 


15 


4 


32 


Other substances 


9 


5 


56 








4 


44 


Maximum No. of implantations of 
















teeth from 1 patient 


60 


58 


97 


2 


3 








Maximum No. of implantations 
















of a single tooth 


35 


33 


94 


2 


6 









Figure 122. 

In order further to test the relation of quantity of infection 
and systemic reaction, it has been desirable to check against the 
infected teeth, the general effect of foreign substances, sterile and 
otherwise. Accordingly, a number of substances have been 
tested. In Figure 122 we show a group of rabbits with subdermal 
implantations of various kinds. In the group there were two 
hundred thirty-seven rabbits, two hundred nine of which had 
teeth of various types implanted beneath the skin. Of this num- 
ber one hundred sixty-five or 79 per cent, are dead at the time of 
this writing, having died spontaneously, and twenty-six or 13 per 
cent, have been chloroformed; eighteen, or 8 per cent are still liv- 
ing. Most of these teeth had been root-filled and were comfort- 
able, so far as the patient was concerned, when they were ex- 
tracted. Some were normal in health and structure, but mal- 
posed, such as third molars; some of these, as noted elsewhere, 



CHAP. XVII QUANTITY, SYSTEMIC EFFECT, AND TOOTH CAPACITY 'I'll 

were removed impactions. Others were treated in various ways 
such as boiling, sterilizing with medicaments, etc. Even im- 
pacted teeth are not necessarily sterile though they probably 
generally are. In six cases sterile coins were used. In these there 
was no local reaction. Thirteen capillary tubes containing in- 
fected material were implanted, of which seven rabbits, or 53 per 
cent, died spontaneously. Miscellaneous substances were used in 
nine rabbits. In this chart, it will be noted that in order to compare 
the virulence of different teeth taken from the same patient, six 
different teeth were successively implanted in sixty rabbits. 
Fifty-eight, or 97 per cent, died spontaneously, and two, or 3 per 
cent, were chloroformed. The maximum number of implanta- 
tions made with a single tooth was thirty-five of which thirty- 
three rabbits, or 94 per cent, died spontaneously, and two rab- 
bits, or 6 per cent, were chloroformed. 

It will naturally be argued that experiments made on animals 
may have little significance in interpreting human defense. In 
the chapter on bactericidal properties of the blood I have shown 
the relative defense of various animals, as compared to the hu- 
man, for streptococcal infection as determined by the methods 
used ; and it is important that few humans have as high a defense 
for the type of dental organism taken from infected teeth as do 
the rabbits. Rats and mice have a still higher defense. 

SUMMARY AND CONCLUSIONS. 

An analysis of these data suggests that pulpless teeth, whether 
root-filled or not, may, if the dental tubuli are not filled, be 
reservoirs of culture media, not only constituting approximately 
one-fifth of the total volume and weight of the tooth, but that 
this quantity is ample to produce very marked systemic disturb- 
ance ; that the quantity of infection in such a tooth is sufficient to 
produce definite lesions in animals and even to produce their 
death. The clinical reaction by the removal of the systemic 
symptoms suggests that the quantity of infection was also 
enough, seriously to aflect the patient. 

We are, therefore, compelled to change the accepted funda- 
mental that infected teeth cannot, if the pulp chamber is properly 
filled, contain infection sufficient seriously to affect the patient, 
to the following: 

Since approximately 5^1 of every root-filled tooth 
is a fluid that can become toxic substance or culture 
media, and in single rooted teeth usually amounts 



228 DENTAL INFECTIONS, ORAL AND SYSTEMIC -RESEARCHES—VOL. I 

to about fifty milligrams, which space may be occu- 
pied by organisms which have access to it from 
either the blood or lymph stream or an exposed sur- 
face of dentin, and since death from typical heart 
lesions has been produced in animals inoculated 
with the relatively small quantity of bacteria, 
washed from a crushed tooth, taken from a patient 
suffering from acute heart involvement, constitu- 
ting an amount of organisms which, by weight, is 
approximately a millionth part of a gram, and since 
the bacteria-free toxin washed from crushed teeth 
frequently produces very extreme systemic changes, 
I believe a single rooted tooth with a well filled pulp 
canal can, under certain conditions, be a source of 
systemic disturbance. I am also led to this conclu- 
sion by our clinical experience with patients. 

When infected teeth produce disturbance in other 
parts of the body, it is not necessary that the quan- 
tity of infection be large, nor is it demonstrated that 
it is necessary that organisms pass throughout the 
body or to the special tissues involved, but the evi- 
dence at hand strongly suggests that soluble poisons 
may pass from the infected teeth to the lymph or 
blood circulation, or both, and produce systemic 
disturbance entirely out of proportion to the quan- 
tity of poison involved. The evidence indicates that 
this toxic substance may under certain circum- 
stances sensitize the body or special tissues so that 
very small quantities of the organisms, which pro- 
duce that toxin, may produce very marked reactions 
and disturbances. 



CHAPTER XVIII. 

STUDIES OF PULPLESS TEETH, WITH AND WITHOUT 

ROOT KILLINGS. 

PROBLEM: Have pulpless teeth injurious contents other 
than microorganisms? 

EXPERIMENTAL AND DISCUSSION. 

A search of the literature has failed to reveal any new light on 
this question. We find no evidence that teeth contain other in- 
jurious substances than bacteria; nor do we find evidence that 
such a research has been made. A large number of studies has 
been made of the organisms which develop in infected teeth, both 
as regards their identity and their biologic and pathologic quali- 
ties. The general procedure has been to take the organisms from 
the suspected teeth by any one of several procedures, culture 
them in suitable media, and test their reactions on various sugars 
and on animals as well as determine their morphologic charac- 
teristics. In this way, a few organisms are increased into a large 
number, presumably of their kind, with the effect that the studies 
are made with new generations grown in new media in a new en- 
vironment; and if many strains are present, those that can best 
adapt themselves to the new medium environment, will necessari- 
ly develop most rapidly and largely overgrow the less adaptable 
types. 

One of our earliest studies in this connection has been the in- 
jection into animals of the washings from freshly extracted and 
finely crushed, individual teeth. Figure 123 is typical. It shows 
two rabbits, full brothers, weighing within a few grams of each 
other, kept continually under the same environment since birth 
and fed on the same nourishment. A was inoculated with the 
washing from the crushings of a tooth, which was centrifuged 
sufficiently to throw down all sediment. A few organisms that 
were washed from the teeth were left in suspension, but only the 
clear supernatant fluid was used. B is the control. It gained in 
weight continually, whereas A began to lose weight slowly. The 
amount of wash injected was 1 cc. of apparently clear water. In a 
few days A showed a loss in weight though there was no apparent 
loss of appetite. Both ate heartily and exercised freely in a roomy 

229 



230 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




J**> 



* > I 



Figure 123. Two brother rabbits of corresponding size 

AND WEIGHT. ALWAYS UNDER SAME ENVIRONMENT. A, THE 
UPPER, WAS INJECTED INTRAVENOUSLY WITH 1 CC. OF THE CLEAR 
CENTRIFUGED WASHINGS OF AN INFECTED TOOTH; B, A CONTROL. 
A LOST 37% AND DIED IN FIVE WEEKS AND B GAINED 12%. 

cage. Week after week A was losing in weight and B was gaining 
in weight. At the end of four weeks, A had lost about 25 per 
cent in weight ; B had gained about 10 per cent in weight. At the 
end of five weeks, A died, having lost about 37 per cent, in which 
time B had gained about 12 per cent. On post, A showed a general 
marasmus with marked atrophy of all muscle tissue, and devel- 
opment of changes in the digestive tract. 

In Chapter 2, I have discussed the morphology and biological 
characteristics of the organisms involved in dental infections. 
In general, we have found that their most important characteristic 
is their power of adaptability. In Figure 24 of that chapter it was 
revealed in the spontaneous deaths the organisms, that were 
washed free from the culture medium and injected into animals, 
killed in an average of seven days, with a loss of weight of 2 per 
cent per day; whereas, when the whole culture was injected, they 
died on an average of six days, with an average loss of 3 per cent 
per day. This suggested that there was some toxic factor present 
in the culture medium that was injurious and was additive to the 
injury of the organisms. 

Our problem in this chapter is to determine somewhat of the 
general nature of these toxic products. To ascertain this, seven- 
teen rabbits were injected with the filtered washings from in- 



v. II W Will s|i DIES I >F PI I I'l ESS Ml III 



231 



fected teeth, and it should be noted that this was nol the washing 
of a quantity of bacterial growth but simply the accumulated 
toxic substance present in a single tooth in each case. Of th< 
seventeen rabbits, thirteen died spontaneously in an average of 
five days, with a loss in weight per day of 3.8 per cent. Inasmuch 
as the organisms which produced the toxin in these particular 
teeth were not the same strains of organisms represented in the 
chart in Figure 24 of Chapter '2, we cannot, by this comparison, 
compare the organisms with their identical toxins. However, 
since the organisms in all these cases are diplococci and strepto- 
cocci, they are, in general, comparable. 

Another most striking result of this experiment was that of 
fourteen rabbits injected with the unfiltered washings, in which 
the toxic substance plus what bacteria would wash from the 
crushed tooth would be involved, eight died in an average of 
twelve days, with a loss in weight per day of 1.8 grams. We are 
at a loss to understand why, in these cases, the toxic substance 
alone washed from the tooth is more rapidly fatal than the toxic 
substance plus the organism, unless it be that it is the presence in 
the blood stream or body fluids of the dead or living organisms 
which furnish the necessary activity to call forth the antitoxins 
to combat this toxic factor. I am inclined to believe that this is 
the explanation. In this chart in Figure 124, it is interesting to note 
that only four of seventeen rabbits lived more than a few days, 
thirteen dying in an average of five days. One of the rabbits of 



COMPARISON OF FILTERED AND UNFILTERED WASHINGS 



Filtered Washings 


No. in 
Group 


Death 


Days 
Lived 


Loss 


Gain 


Actual 


% 


% 
per day 


Actual 


% 


/o 
per day 


3 

1 

13 


Chloroformed 
Chloroformed 
Spontaneous 


33 

44 

5 


56 
191 


5 
19 


1 
3.8 


176 


18 


.4 






Unfiltered Washings 








5 

1 
8 


Chloroformed 
Chloroformed 
Spontaneous 


32 
20 
12 


191 
221 


10 
22 


.5 

1.8 


171 


14 


.4 



Figure 124. 



232 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

this group received a washing which, apparently, was not at all 
toxic, or but slightly, for it gained 18 per cent in forty-four days; 
and, similarly, five of the group of fourteen that received the un- 
filtered washings, gained an average of 14 per cent; whereas, all 
the others in each group lost in weight. In the chapter on Sensi- 
tization, I have discussed the matter of the ability of these toxic 
substances to sensitize tissues of the host so that when later in- 
jected with the toxic substance or when the organisms producing 
it are injected into the host, the reactions are much more violent 
than otherwise. One rabbit died within a few minutes. 

These data suggested to us that we are dealing with products 
in freshly extracted, infected teeth, which differ essentially from 
those developed by culturing the organisms from the same. We, 
accordingly, made determinations of the difference in the re- 
actions when the organisms were removed from the washings, and 
found that in many instances that after passing the washings of 
the crushed tooth through a fine Berkefeld filter very similar dis- 
turbances were produced in animals even though the cultured 
filtrate developed no organisms. It was found that, whereas the 
organisms, when injected, tended definitely and regularly to pro- 
duce lesions in various organs and tissues, the filtrate produced 
disturbances of metabolism and nutrition, with its principal 
effects upon the digestive tract and nervous system. It is evident 
that we are dealing in infected teeth with a substance which has 
very profound effect in very small quantities. The substance is a 
very complicated one which does not lend itself readily to con- 
centration, as will be shown later. 

We have next inoculated succeeding groups of animals with the 
filtered washings from teeth, and then tested these animals to 
determine whether they were more sensitive to the organisms 
grown from those teeth than our normal animals ; and it has been 
found that whereas the controls — namely, the animals that had 
not received a preliminary injection of the filtrate — developed 
lesions in one or two weeks and usually recovered according to 
the sizes of the doses used in the tests, the animals that were in- 
oculated with the filtrate usually developed their symptoms much 
more rapidly and severely. A much larger percentage died and 
often within a day or two; and in a few instances, the preliminary 
injection of the filtrate so prepared the animal for the bacterial 
injection that it died within thirty minutes to two hours, and in 
one instance in a few minutes; whereas the controls lived for 



CHAP. W IN Ml DIES OF PI 1 PLESS I EETH 

weeks and often apparently recovered entirely. We believe this 

is one of the most important of the main- new discoveries of our 
work. Its interpretation and significance are given in Chapters 
if) to 56. 

Sl'MMARY AND CONCLUSIONS. 

We are, therefore, led from these studies to conelude: 

That the organisms found in infected teeth are 
not the only product of that tooth which may dis- 
turb the host, that toxic substances are formed in 
the tooth which may pass from that tooth to the 
host, and in some instances (perhaps in many) tend 
to prepare the host for the invasion by that organ- 
ism, and may, either in addition or separately from 
that process, produce definite disturbances of 
metabolism within the host. 

We wculd, accordingly, change the old fundamental : namely, 
that the only injurious substance which infected teeth may 
contain is a bacterium; or infected teeth contain no other injurious 
substances than microorganisms, to: 

Infected teeth may contain in addition to 
microorganisms toxic substances, which produce 
very profound effects upon experimental ani- 
mals and, which tend to prepare the tissues of the 
host, at least in some cases, for a more ready inva- 
sion by the organisms growing in that tooth. 



CHAPTER XIX. 
HEMATOLOGICAL CHANGES IN THE BLOOD. 

PROBLEM: What changes are produced in the blood and 
sera of the body by dental infections? 

EXPERIMENTAL AND DISCUSSION. 

While it has been known for a long time that many patients 
suffering from rheumatic group lesions, which have affected 
various of the harder tissues, such as the muscles and skeleton, 
nervous system, circulation, digestive tract, etc., there seems to 
have been very little work done to determine the effect of dental 
infections upon the various sera of the body. An analysis of over 
one thousand blood counts of animals discloses, that, whereas a 
given strain of organisms tends to produce, in general, the same 
changes in the blood picture, different strains may produce wide- 
ly different results. 

Figure 125 shows a group of rabbits which received their infection 
by having teeth planted beneath the skin. These were such teeth 
as were condemned because of suspected systemic involvements of 
the patients. We have selected for this group a series having from 
two to three counts and in which there has been an increase in the 
erythrocytes. It will be noted that in two instances, five are 
from the same patient. 

Similarly, some cultures and implanted teeth tend to produce 
a decrease in the erythrocytes and, occasionally, very marked 
decrease. In Figure 126 we have a group of rabbits showing de- 
creases in both the hemoglobin and erythrocytes, which are 
typical. The first decreased from 6,750,000 to 4,600,000 in 
twenty-four hours. The hemoglobin decreased 5 per cent, and 
incidentally, there was a decrease in the leucocytes. These, how- 
ever, will be discussed in subsequent paragraphs. This rabbit was 
inoculated with culture. The second had a tooth implanted be- 
neath the skin. The hemoglobin reduced 5 per cent, and the 
erythrocytes from 6,900,000 to 4,200,000 in eight days. The 
third shows a quite remarkable picture. This rabbit had a tooth 
planted beneath the skin; and while its hemoglobin remained 
constant, the erythrocytes reduced from 4,050,000 to 1,650,000, 

234 



CHAP. XIX HEMAT0L0GICA1 CHANGES BY DENTA1 INFECTION 

ER\ I'HKiH. ^ rOSIS PR( M>i CED B\ TOOTH 1MIM.W I \im\s 



Case 

N 


Rabbit 

N 


Date 


Ei \ throcytea 


C ise 
No 


Rabbit 

V 


Dat • 


Erj throi 


1236 
1215 


813 


2 1.. 22 
2 23 22 


3.900.000 
1,000 




879 


3 20 22 

3 27 22 

2 18 22 
2 20 22 


1.000 
1,000 

1.50(U)(M) 


820 


2 15 22 
2 23 22 


2.ti00.000 

5,650.000 


1222 


S2S 


1215 


82 1 


2-15 22 
2 19 22 


2,056.000 
3,050.000 


1211 


882 


3 22-22 
3 27-22 


5.700.000 
6,700,000 




822 


2-16-22 

2 22 22 

3 29 22 
3-30-22 


1.050.000 
2,750.000 

;>.2u).ooo 

8.500.000 


1211 


894 


3-22-22 
4- 4-22 

3-22-22 
3-24 22 
1 11-22 


4,30i 1 
1,000 

1.200.000 
5.500,000 
6.450.000 


(582 


881 » 




824 


2-16-22 
2 23-22 


1.080.(HK) 

3.9:.o.ooo 


838 


2-22-22 
3- 2-22 


2,750.000 
3.750,000 


825 

82b 


2-17-22 
2-23-22 
2-28 22 


7.700.000 
6.750.000 


839 


2-22-22 
3- 2-22 


1.750,000 
3,750,000 


2-17-22 
2-25-22 
2-28-22 


4.800.000 

5.050.000 
9.750.000 


81H 


2-22-22 
3- 2-22 


2,750,000 
4.750,000 




851 


3- 8-22 
3-20-22 
4-15-22 


1.450.000 
2.450.000 
6.200.000 




843 


2-22-22 
2-25-22 


2,400.000 
3.400.000 


1170 


827 


2 18 22 


i n^n nno 


33 ; 


871 


3-17-22 
3-20-22 
3-24-22 
3-23-22 
4- 4-22 
4-15-22 


3.050.000 
1.300,000 
5.900,000 
6.300,000 
7.050.000 
6.900,000 


2-20-22 i 2.050.000 
2-22-22 | 6.550.000 


1205 


831 


2-20-22 1 3.080.000 
2-22-22 5.050.000 



Figure 12o. 



ERYTIIROPENIA 



Case 
No. 


Rabbit 

No. 


globi°n Erythrocytes 


1322 


960 


80 
75 


6.750.000 
4.600.000 


1119 


1057 


85 
85 
80 


6.900.000 
5,800.000 
4,200.000 


692 


849 


80 
80 
80 


4,050.000 
5.050.000 
1,650.000 


692 


868 


80 
75 
75 


3.600,000 

2,900.000 

750,000 



Figure 126. 



236 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 



and the color index raised from 0.9 to 2 in twelve days. The 
fourth rabbit had a decrease in the hemoglobin from 80 to 75; 
the color index raised from 1 to 4 ; and the erythrocytes reduced 
from 3,600,000 to 750,000 in six days. 

The most striking changes in blood morphology, however, have 
been produced in the various types of leucocytes, expressing them- 
selves generally at first by leucocytosis, followed by a leucopenia. 
A group of these typical changes in leucocyte count is shown in 

LEUCOCYTOSIS PRODUCED BY TOOTH IMPLANTATIONS 



Case 
No 


Rabbit 

No 


Leucocytes 


Case 
No 


Rabbit 
No 


Leucocytes 


1367 


1135 


9,000 
13.000 


1317 


1186 


5,600 
6,900 
4,000 
2,600 


1134 


8,300 
11,400 


1388 


1204 


7,900 
20,000 


1370 


1154 


8,000 

11,000 

6,100 


1394 


1211 


8,600 
18,000 


1390 


1158 


8,400 
17,600 


404 


1153 


8,200 

6,200 

10,800 


1353 


1169 


8,800 

10,000 

8,200 


355 


1173 


10,800 
10,200 
12,200 
23,800 


1363 


1170 


8,200 
10,200 
9,800 
9,300 
5,600 


1385 


1175 


15,300 
14,400 
25,400 



Figure 127. 

Figure 127. The most striking effect, however, of the effect of 
the infection on the leucocyte count is expressed as a marked 
leucopenia, the reduction of leucocytes frequently being very 
great. This is shown in Figure 128. 

For years I have been noticing a type of blood picture in pa- 
tients suffering from dental infections, which is characterized by 
a low polymorphonuclear count and a high small lymphocyte 
count ; and these studies seem to have thrown a new light upon 
this condition. I had noticed that it often changed, returning to 
or toward normal in the patients after removal of dental infec- 
tions. In Figure 129 I show the successive counts of a series of 
eleven rabbits, each one of which had a tooth implanted beneath 
the skin. The first reading in each case was made before the 



CHAP. \l\ HEMATOLOGICAl CHANGES B\ DENTAL INFECTION 237 



LEUO IP] M \ PRODUCED BY TOOTH 
IMI'l \\ I ATIONS 



Case v 


Rabbil No 


I. (linn vies 


1317 


1167 


1 1 .500 
7.200 


1186 


5.600 
6,900 
1,000 

2,600 


1387 


1 1 78 


10.8(X) 
9,600 
5,000 
6.000 


1377 


1208 


25.000 
7,000 



Figure 128. 

implantation and represents approximately the rabbit's normal. 
In this series, we have shown in heavier faced type, the polymor- 
phonuclears and small lymphocytes, and it will be noted that in 
every instance in this group there was progressive depression 
of the polymorphonuclears, with a corresponding increase in the 
small lymphocytes. The average percentage decrease of poly- 
morphonuclears is 33 and the average percentage increase of small 
lymphocytes 58. It is interesting to note that while the very 
serious changes in the different types of leucocytic cells have oc- 
cured, there has been very little change in the hemoglobin of these 
animals, as shown in that column. It is also important to note 
the slight change that has been produced in the erythrocytes in 
these cases. In the third and fourth column we have shown the 
weight changes, total and per cent, and it is important that in 
those cases with very marked loss in weight (for all of these rab- 
bits lost in weight,) almost in proportion with the loss there has 
been the depression of the polymorphonuclears and an increase 
in the lymphocytes. We have here an expression of the phases of 
blood morphology that are involved in the Walker Index, which we 
have discussed chiefly in the chapters on systemic involvements 
in patients, in which cases we have referred occasionally to the 
negative Walker Index. 

An illustration would be shown in Case No. 1228, in which the 
patient was suffering from acute heart involvement and acute 
rheumatism with albuminuria, with evidence of direct relation- 
ship to focal dental infections. The polymorphonuclear count 



238 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 



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CHAP. XIX HEMAT0L0GICA1 CHANGES B1 DENTAL INFECTION 239 



was 83 per cent, which would call for a leucocyte count of at least 

23.000 and she only had 10,500. She, accordingly, had a Walker 

Index of 12. A blood culture was, accordingly, made, and the 
same strain of streptococci was found in the patient's blood as 
was found in the extracted tooth. With the removal of her den- 
tal infections, her condition improved very greatly. Her Walker 
Index reduced to 4 ; and, when taken later when the patient was 
normal, her Walker Index had returned to approximately normal. 

PATIENTS W I1II DEPRESSED IMl.YMOKl'llONl VI.KAKS AND INCREASED SMALL LYMPHOCYTES 



Case 

\ 


Hemo- 
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Erythrocytes 


Leucocj tes 


Polymor- 
phonu- 
clears 


Lymphocj tes 


Mono- 
nuclears 


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Large 


1381 




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7.200 


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3 5', 


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1267 


• 


5.600.000 


7.800 


48 .V , 


42 0' , 


6.095 


2 O', 


0.5 


1311 




5.800.000 


5.200 


56 .V , 


34 it 


6.2', 


2 6', 


9 


1 105 




1.700.000 


7.800 


58 3 


36 .V, 


3 6', 


0.8', 


5', 


1 103 




5.750.000 


6,800 


50 0' , 


42 0' ( 


4.5 


2.5', 




1101 




5.300.0(H) 


5,600 


56 N 


34 . 1 95 


5.4', 


2.7% 


10', 




85' , 


5,100.000 


9,240 


50 <)', 


40 0\ 


8 5', 


1 0', 


5', 



Figure 130. 

In Figure 130 we show a groupofconsecutivecases, being patients 
suffering from dental infections of long standing and all showing 
systemic involvements which I have interpreted to be influenced 
directly by the dental infections, if not largely produced by them. 
When we compare these with a case (Case No. 1385) of acute 
rheumatism which developed suddenly following a chilling of the 
patient, whose defense was lowered and who at the same time 
was carrying such chronically infected teeth, we find his blood 
count as follows : 

Hemoglobin 90% 

Erythrocytes 5,500,000 

Leucocytes 16,000 

Polymorphonuclears 78.6% 

Small lymphocytes 13.8% 

Large lymphocytes 4.1% 

Mononuclears 3.0% 

Eosinophiles 0.5% 

Color Index 0.8 

Note that his polymorphonuclears are 78.6; his small lym- 
phocytes, 13.8. It must not be understood that I am presuming 
that all cases of low polymorphonuclear count have dental in- 
fections, nor that all patients with a high lymphocyte count, or 



240 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

both, have thereby an evidence of dental infection. I am sub- 
mitting for your consideration the fact first that it occurs in the 
patients with chronic dental infections, and that it develops in 
our experimental animals in which we produce such states. 

SUMMARY AND CONCLUSIONS. 

While the data available are not sufficient for detailed deduc- 
tions, they strongly indicate that there is much significance from 
both the pathological and diagnostic viewpoints in the blood mor- 
phology and its changes. The evidence strongly suggests that 
the toxic elements involved in the infection process have distinct 
and harmful effects ; and while the reaction to infection of a nor- 
mal defense is characterized by a leucocytosis (a fact which is 
quite universally recognized), it seems quite as universally true 
that certain types of infections, such as those produced by the 
planting of a tooth beneath the skin of a rabbit, have destructive 
effects, particularly on the polymorphonuclears, the depression 
of which decrease in the presence of the increasing infection, spells 
a very bad omen in the case of our animals, and practically always 
terminates in death. It, therefore, seems probable that our pa- 
tients, who show a very marked leucopenia, and particularly 
with a markedly depressed polymorphonuclear count, are under- 
going a degenerative process. Our application of this is discussed 
in Chapters 45 to 56. 

We would, accordingly, condense the conclusions of this 
chapter to the following: 

Dental infections may produce very serious 
changes in the blood and sera of the body, some of 
the most frequent of which are leucopenia, erythro- 
penia, lymphocytosis, and hemophilia. 



CHAPTER XX. 
CHEMICAL CHANGES OF THE BLOOD. 

PROBLEM: What are the chemical changes that are pro- 
duced in the blood by acute and chronic dental focal 
infections? 

EXPERIMENTAL AND DISCUSSION. 

The preceding researches led us step by step through clinical 
expressions of dental infections, local and systemic, through a 
channel that has led us back into a mountain vastness, unin- 
habited and unexplored, and quite uncharted. I was led to make 
this mode of attack as a result of the study of the apparent causes 
of success and failure in the various lines of research that have 
been conducted, for apparently exceedingly few solutions to 
problems have been found by a direct attack on fundamental 
problems. The symptoms of dental infections are their clinical 
expressions. By association and exclusion we have been able to 
type the local structural expressions and also the physical mani- 
festations. These have led directly to changes which occur in the 
hard structures of the body as increases or decreases in the density 
of a bone, and in the soft tissues as edema, atrophy, and disfunc- 
tion. If rarefying osteitis is associated with an entirely different 
type of defense and reaction from that which obtains when con- 
densing csteitis develops, it would seem most logical that those 
elements which are directly related to bone formation and tissue 
function must be most vitally involved. Accordingly, from nearly 
every research that has been herewith recorded, we have had evi- 
dence pointing directly to those factors which are most intimately 
related to metabolism and bone formation. 

As a first approach we have made blood analyses of many hun- 
dreds of patients and animals to determine, if possible, what 
factors are most variable in the different clinical expressions and 
to what extent. In Figure 131, I show 146 successive blood 
chemical analyses for 92 successive patients, some individ- 
uals having had several determinations made. In these studies 
we have determined, in general, blood sugar, (Usually the first 

241 



242 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 



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Figure 131 (A) 



CHAP.XX CHEMICAL CHANGES IN BLOOD BY DENTA] INFECTIONS 243 



1 


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o 

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3 
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Brain disfun 
spasmodic. 


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proved. 


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Figure 131 continued (B) 



244 DENTAL INFECTIONS, ORAL AND SYSTEMIC-RESEARCHES— VOL. I 



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Figure 131 continued — C. 



CHAP. XX CHEMICA] CHANGES IN BLOOD B^ DEN I M. INFE< HONS 245 



"33 
1 

z 


Z 

li 

>>- 

X 


1 

3 


Very acute rheu- 
matism and heart 
involvement 
Normal. 


Mild nephritis. 


q 

£ 
u 


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3 
V 


■Q 

u 
3 

i 

U 

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deforming arthri- 
tis. 


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litis. 


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down. 


s 

o 

u 

S 


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Figure 131 continued— D. 



246 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 



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248 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

reading was not made after fasting as is required for a determina- 
tion of hyperglycemia. When, however, such seemed indicated 
this was done.) non-protein nitrogen, uric acid, urea, acid-base 
balance, alkali reserve or a C0 2 combining power, also expressed 
as alkalinity index, ionic calcium, calcium pathologically com- 
bined, thrombin content, total calcium (including the ionic, 
pathologically combined, and the physiologically combined, such 
as calcium proteinates, etc.) It will be noted from reviewing this 
table that there is a very great variation in these different chem- 
ical constituents of the blcod in the different individuals, and this 
very extensive study has involved the relating of these to the 
various pathological states, and particularly to the dental condi- 
tions and the changes in these and the physical symptoms or 
involvements, with the changes in the dental focal infection 
elements. 

When, now, we relate the general clinical symptoms and physi- 
cal conditions of these patients with these data, there are certain 
factors that we find quite universally associated. It will be 
noted, for example, that with few exceptions the high readings of 
blood sugar are found associated with high ionic calciums of the 
blood. While there are very few exceptions, this becomes an 
association which has a quite constant significance, as we will see. 
Another striking association is the practically universally high 
ionic calcium in cases of acute periodontoclasia. Similarly, cer- 
tain types of susceptibility and involvement with rheumatism 
and neuritis, tend to be associated with a depressed ionic calcium 
of blood. We have, accordingly, divided these patients out into 
groups and studied them intensively in connection with these 
various factors, and have made a very large number of animal 
inoculations and subdermal tooth implantations, and checked 
these chemical changes of the blood against these established 
conditions. These will be reviewed in detail. 

But these studies have tended to be quite indefinite with regard 
to the calcium, for some groups of individuals with approximately 
normal total calcium have included many cases with definite 
rheumatic group lesions, for while there was enough total calcium 
present it did not seem to be available for normal metabolic and 
catabolic processes. Another great difficulty has been the varia- 
tion that has developed in the calcium determinations as made 
by different methods. It has been known for some time that 
calcium is present in the blood in two principal forms : ionic and 



( HAP. \\ ( HEMIC M ( HANGES l\ I'.l odd kv DEN I AL 1MB I [( INS 249 

combined, the latter including the various calcium proteinat 
We have, accordingly, spent a great deal of effort lo determine 

the amount of the ionic calcium as well as the total calcium and, 
where possible, the pathologically combined calcium for the vari- 
ous types of lesions. We have found that in a large percentage of 
cases of certain types of rheumatic group affections there is at tin- 
time of the active process a low ionic calcium; and, furthermore 
that as the ionic factor approaches normal, the symptoms disap- 
pear. In the coagulation of normal blood, calcium is a funda- 
mental factor; but instead of ionic calcium's being taken up as 
might be anticipated in that process, it is, as a matter of fact, 
liberated, for the ionic calcium of the plasma of uncoagulated 
blood is lower than that of the serum of coagulated blood. (The 
fluid of the circulating blood is referred to as the plasma and the 
fluid which separates out from the coagulum of coagulated blood, 
as the serum.) 

Normal blood should contain from 10 to 10.7 milligrams of 
calcium per 100 cubic centimeters. When the blood is in circula- 
tion, approximately four milligrams of the calcium are carried in 
combination with the thrombin, a little less than a milligram in 
the blood cells and about six milligrams as ionic calcium. In the 
clotting process the four milligrams in combination with the fi- 
brinogen will be released in the process of the formation of fibrin 
and will appear as freshly ionic calcium in the serum. Accordingly, 
if, in any individual the total calcium be reduced four milli- 
grams — namely, from ten milligrams to six milligrams — the four 
milligrams which are combined with the fibrinogen will not be 
available in the circulation as ionic calcium, and the total ionic 
will be reduced to two milligrams; in other words, in this case 
there is a reduction of two-thirds from normal, whereas the total 
calcium has only been reduced a little more than one-third. 

From this it will be seen that determinations of the total calcium 
may be very misleading. No problem with which we have 
been engaged has compared in difficulty with this one of the mak- 
ing of dependable determinations of the quantity of calcium in 
different states in the blood. It will readily be seen that any 
incineration method can only give total quantities, since the ash 
can give no indication of chemical structure of destroyed com- 
pounds. Nor have we, as yet, dependable quantitative chemical' 
reactions that will differentiate with certainty the ionic calcium 
from the combined calcium though, no doubt, experimental 



250 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES -VOL. 1 

methods will be improved very rapidly, to make this 
more easily possible. We have, however, biological" methods 
for making these determinations and we have, accordingly, de- 
pended on these. 

Similarly, we have determined the amount of calcium patho- 
logically combined in different stages of the treatment of a rheu- 
matic group lesion. Figure 132 shows the progressive stages toward 
normal, of a case in which the pathologically combined is ex- 
pressed. It will be noted from this chart that the ionic calcium 
began at 7.5, with a pathologically combined factor of 2.2. This 
patient was suffering from a recurring infective process for months 
after a mandibular extraction had been made under gas. No 
sequestra ever formed, and there was no direct evidence of an 
osteomyelitis. The condition came finally to involve the fascia 
and musculature of the neck and side of the face, with much en- 
largement of lymphatics, which ultimately required deep surgical 
drainage. Gauze packs were replaced daily for months, and the 
cellulitis tended to increase. The method of treatment will be 
discussed in detail in the chapters on the glands of internal secre- 
tion (Chapter No. 37) and methods for reinforcing a deficient 
defense (Chapter No. 42). The important thing in this connec- 
tion is to note that with the progressive increase in his ionic cal- 
cium, whether as a cause or an effect, there was a marked im- 
provement in his physical condition. From the 31st of August to 
the 13th of September (two weeks' time) there was an increase in 

Important references. See bibliography for others. 

10. Kramer, Tisdall, Howland: The clinical significance of calcium concentration in the 
serum of children and possible errors in its determination. Am. J. Dis. Child. 22:560, Dec. 
'21. 

11. West: A new method for the determination of calcium and thrombin in serum: 
J.A.M.A., Vol. 78, No. 14, Apr. 8, 1922, p. 1042. 

11. Vines: Parathyroid therapy in calcium deficiency, Proc. Roy. Soc. Med. (Sect. 
Therap. & Pharm.) 15: 13-18, March '22. 

11. Vines & Grove: Calcium deficiencies: their treatment by parathyroid, Brit. M. J. 
1:791-795, May 20, '22. 

11. Vines: Coagulation of blood, Part 1. Role of calcium, J. Physiol. 55:86, May '21. 
Coagulation of blood, Part 2. Clotting complex, J. Physiol. 55:287, Aug. '21. 

1 1 . Vines & Grove : Control of hemorrhage by intramuscular injection of calcium chloride, 
Brit. M. J. 2:40, July 9, '21. 

Etiology and treatment of varicose ulcers, Brit. M. J. 2:687. Oct. 29. '21. 



CHAP W CHEMICAL CHANGES IN BLOOD B1 DEN l \l I Ml a riONS 25] 
i l l l K I OF rREATMENT ON IONK CAL< H M OF BLO >l I 



Date 


1 lout 
\ M 


1 MMtmrtlt fol 

Ionic Caldum 


Ionic 
Normal 
Serum 


lonii 
I n tted 
Serum 


c omb 
Patho 
logical 


S 31 22 


9:00 


Began 




9 7 


2 2 


9 c> 22 


10:00 


Continued 


7 9 


9 9 


1 9 


9 13 22 


11:00 


Continued 


<X 1 


9 •■ 


1 1 


9 26 22 


1 1 :00 


Continued 


8 2 


9 I 


1 2 


1 21 23 


11:00 


Discontinued 


10 6 


11 ii 


3 


2 16 23 




Resumed 


9.2 


11 1 


1 8 


■1 25 23 




Continued 


9.4 


9.9 


5 



Figure 132. 

the ionic calcium of the blood of 0.6 mg. per 100 cc, and a de- 
crease in the pathologically combined of 0.8 mg. This patient 
had been in a process of decline for a couple of years and had been 
unable to carry on his work for many months, and with his age 
of fifty-seven and the seriousness of his disturbance, it seemed 
very probable that with his progressive and continuous decrease 
in defense with increase in the severity of his conditions, he was 
heading for a complete, and perhaps final break. With his low 
defense and the history of previous surgical procedures, which 
seemed to give only temporary benefit, hope for material assist- 
ance by that means was not indicated. 

However, under treatment for the increase of his ionic calcium, 
his change was most rapid and remarkable. Not only did his 
state of impending doom give way to one of confidence and 
courage, but he gained in weight and physical endurance so 
rapidly that in a few weeks' time he was back to his office, carry- 
ing not only one man's work, but two or three, and notwithstand- 
ing his tremendous overload, went on gaining progressively as 
his ionic calcium increased; and in about four months it was up 
to normal, 10.6, and his pathologically combined had decreased 
to 0.3. His facial condition and neck involvement entirely disap- 
peared spontaneously and never recurred. At this time the 
treatment was discontinued and in about three weeks' time his 
ionic calcium had decreased to 9.2 and his pathologically com- 
bined had increased to 1.8. The treatment was resumed and in 
nine weeks, notwithstanding an excessive overload and worry, 
his condition again improved, the ionic increasing to 9.4, and the 
pathologically combined (which is very important) decreased 
from 1.8 to 0.5. 

It is a very common occurrence in connection with the study of 



252 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

these cases to find that accompanying the general physical de- 
pression there is a mental depression which I have termed "Men- 
tal Cloud", which varies in severity from a sense of impending 
doom to one of lack of courage. It is quite remarkable that this 
depressed mental state tends rapidly to disappear with the in- 
crease in ionic calcium toward normal. I have discussed this in 
further detail in the chapter on mental diseases. 

Perhaps no phase of local and systemic involvement from den- 
tal infection is more frequently manifest than the disturbances of 
the circulation, both local and general, the most readily dis- 
cerned of which, both by the patient and the operator, will be 
disturbances of coagulation ; and it will be seen that these studies 
throw a flood of new light on secondary postoperative hemor- 
rhages, bleeding gums, etc. This may either be a temporary 
expression or a quite general and extended one. It will also be 
possible for us to distinguish quite clearly between an hereditary 
hemophilia and a pathologically produced one. An extreme 
illustration of the latter will be seen in the following case. 

Case No. 1084. — The patient was presented with a history of 
hemophilia so serious that he felt he was bleeding to death, and 
on several occasions his life had been despaired of. During the 
preceding two weeks he had had two transfusions to restore, if 
possible, the clotting ability of his blood. The hemorrhage was 
practically continuous from the gums, with occasional epistaxis. 
A tooth had been extracted three months previously and its sock- 
et was still bleeding. There was some hemorrhage from his 
gums practically every moment night and day. On a careful 
study of his case I observed that the hemorrhage was greatest 
around his non-vital teeth, none of which showed either extensive 
areas of absorption or were the least tender. (See Chapter 60) 
Inasmuch as I had several times had strains of organisms from 
dental sources that produced spontaneous hemorrhages in rab- 
bits, I suspected that the teeth were providing some substance 
which was acting directly upon the blood, whatever other sources 
there might have been for his disturbance. He was barely able 
to walk; had to be assisted up all steps; was exceedingly weak and 
of ashen color. Notwithstanding the great danger attending an 
extraction, through the difficulty of controlling the hemorrhage, 
it seemed very desirable that his pulpless teeth be removed, both 
in order to relieve him from their injurious effect, if such existed, 
and to secure a culture for making a vaccine to reinforce his 



CHAP. XX CHEMICAL CH tNGES IN BLO ID B"V DEN I AL IMIa I IONS 

systemic defensive reactions. Great difficulty was experienced 
in controlling the hemorrhage following the extraction, a com- 
press being required night and day for several clays; and in spite 
of this, approximately 100 cubic centimeters of blood were lost in 
a few hours following the extraction. It is sufficient to state here 
that, with the use of a vaccine and the elimination of his dental 
infection his clotting time reduced progressively from eight and 
ten minutes at the time of the first extraction, to three and three 
and one-half minutes; and after the first extraction I had little 
trouble in controlling postoperative hemorrhage. In a week's 
time practically all spontaneous hemorrhage had ceased; and in 
four weeks' time he was carrying on his work approximately 
as normal. 

But this is not the only important part of the history. Cultures 
grown from the interior of these teeth, and injected into a large 
number of rabbits, produced in many of them serious and early 
disturbances in the blood stream. Many had spontaneous hemor- 
rhages and very marked change in the clotting time of the blood, 
even extending to ten minutes from a normal of from one-half 
minute to one minute and one-half. In the chapter on circulation 
disturbances there will be seen a series of cases, including 
this one, of spontaneous hemorrhages produced in rab- 
bits when inoculated with the cultures from the teeth of 
patients suffering from hemophilia. One of the above rabbits 
inoculated with the culture from this case and shown in a later 
chapter referred to, died in twenty hours of spontaneous hemor- 
rhage in the thigh and kidney, so profuse that although the effort 
was made promptly, we could not get enough blood from the heart 
and blood vessels to make a chemical analysis, a most unusual 
experience. 

While the injurious effects of infections on the blood are by no 
means limited to the disturbance of the coagulation mechanism, 
this change is perhaps the most readily seen of any, and it is also 
very easily determined with instruments that are adapted for 
that purpose. It will be instructive, to note the progressive 
change in this patient. In the first three days after his first ex- 
traction, the clotting time decreased tw r o minutes (from eight to 
six) . He then had a slight reaction, and for three days it required 
seven minutes. In two weeks' time it had decreased two and one- 
half minutes to five and one-half minutes, and then decreased 
about a minute a week, reaching four minutes in about four weeks 



254 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

and three and one-half minutes in eight weeks. The spontaneous 
hemorrhages ceased the third day after the first extraction. 

The chemical analysis of this patient's blood showed the CO, 
combining power to be 68, non-protein nitrogen 27, and blood 
sugar on one occasion 180, on another 158; the creatinin on one 
occasion 0.9, and another 1 ; blood urea on one occasion 8.4, on 
another 9.7; uric acid on one occasion 4.15, another 2.7; total 
calcium 8.16. At this time (April, 1921) we were not separating 
the calcium present in the blood in accordance with the amount 
present in ionic form, the amount pathologically combined and 
that physiologically combined, and total calcium. This figure 
would represent simply the total; and inasmuch as the total was 
reduced below the point of safety for the ionic alone, it is evident 
that this patient was in a state of very great calcium depression. 
Our later cases with our greatly improved method (though not 
as yet completely adequate and satisfactory) have thrown much 
additional light on these conditions. 

A careful study of the data furnished in this case and several 
showing blood changes, which latter showed very marked im- 
provement after the removal of infected teeth, led to the general 
conviction that the teeth in certain cases provided a substance 
which combined directly with the ionic calcium of the blood and 
removed it from availability, though remaining in the circulation. 
This is also very strikingly suggested by the very nature of both 
condensing and rarefying osteitis. In order to test this, we have 
made a series of studies of the effects of the extracted teeth on 
drawn blood of the patient from whom the tooth was extracted to 
determine its effect directly upon the available ionic calcium, and 
have found most important new data. Figure 133 shows a series 
of such teeth and the amount of depression of the ionic calcium 





] 


BLOOD CALCIUM CHANGES PRODUCED BY INFECTED TEETH 










Calcium 




Tooth Placed in 


Serum 


Decrease 
in 


Total in 
Pathological 
Combination 


Case 
No. 


Ionic 


Ionic 
and 


Patho- 
logically 


Ionic 


Ionic 
and 


Patho- 
logically 


Ionic 
















combined 


combined 




combined 


combined 


Actual 


% 


Actual 


% 


1325 


9 86 


10.58 


0.72 


8 95 


9.38 


0.43 


-0 91 


-10 


1 63 


15 


817 


9 89 


10.13 


0.24 


8 66 






-1 23 


-13 


1 47 


15 


1363 


11,904 


15.40 


3.496 


12 732 


13.44 


0.708 


+ 0.828 


+ 7 


+ 2 66 


17 


1353 


11 920 


11 . 920 




8 51 


9.16 




3 41 


-29 


-3 41 


28 


1350 


9 06 


9.66 


0.60 


8 54 


12.58 


4 . 04 


52 


- 6 


-1.12 


12 


1404 


11 802 


13.334 


1.532 


7.258 


11.802 


4.514 


-4 544 


-38 


-5 076 


38 


1267 


8 10 


9.53 


1.43 


6 05 


8.13 


2.08 


-2 05 


-25 


-3 51 


37 


1315 


5.25 


7.50 


2.25 


1 25 






4 00 


-76 


-6 25 


83 



Figure 133. 



CHAP. XX CHEMK \l CHANGES IN BLOOD B"V DEN I \i INFE( riONS 

produced in the blood of the patient from whom the tooth was 
extracted. It will be seen that some teeth produced practically no 
effect; most non-vital teeth of long standing, some effect; and 
some, very profound effect. For example in Case No. 11-J15, it 
will be seen that the ionic calcium of the blood was reduced from 
5.25 mgs. per 100 CC. to 1.25. This patient was very ill, and the 
indications were very strong that her dental infections were seri- 
ously contributing to her illness. In this group we have several 
different types, and it is very significant that the teeth of the 
fourth, sixth, seventh, and eighth cases, which produced depres- 
sions in the ionic calcium of the blood of 25 per cent or more, the 
last 76 per cent, were taken from patients with a very marked 
evidence of physical injury, one expression of which was the 
symptoms of systemic involvements from dental infections. In 
only one case was there an increase in the ionic calcium (Case 
No. 1363), and in it the total ionic and pathologically combined 
was abnormally high, 15.4 mgs. per 100 cc, and it seems probable 
that the presence of the tooth in this patient's blood, carrying 
3.49 mgs. of pathologically combined calcium, acted in some way 
on that element of the blood. In the last column we have added 
the original pathologically combined and the newly combined 
from the presence of the tooth, and it will be noted that in the 
last case of the original 7.5 mgs. of calcium, ionic and pathologi- 
cally combined, in this patient's circulating blood after the pa- 
tient's tooth was placed in the blood there was only 1.25 ionic 
available, or the total combined of this individual's blood after 
placing the tooth in it was 83 per cent. In the last column we have 
expressed in percentage that part of the calcium of the blood 
which should have been available but was in pathological combi- 
nation: namely, the pathologically combined of the circulating 
blood plus the pathologically combined produced by placing the 
tooth in some of the freshly drawn circulating blood. It will be 
noted that these percentages run from 15 to 83, with four of the 
eight 28 per cent or over, with an average for the eight cases of 
31 per cent. 

It is, therefore, not surprising that if an infected tooth within 
one hour's time will seriously depress the ionic calcium, that the 
continued presence in the system of such a toxic substance must, 
of necessity, unless there be some powerful sterilizing agent, exert 
a very definite and serious influence on the blood. If, instead of 
a single tooth, the patient has several producing such a toxic sub- 



256 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

stance and is not able to neutralize their products immediately 
about the tooth, grave systemic results should be expected to 
occur. It is, accordingly, just what should be expected, that so 
usually develops that when infected teeth are removed from the 
systems of patients suffering from depressed ionic calcium, that 
lesion automatically decreases or disappears. In another chapter 
on the glands of internal secretion I have discussed some phases of 
Nature's mechanism for neutralizing these poisons. 

By studying the data in the next chart it is very readily 
seen that there is a constant relationship between the ionic 
calcium and metabolism, for continually with a decrease in 
ionic calcium there is a decrease in the weight. I have under- 
taken, therefore, to study this phase more exactly in order to 
determine, if possible, somewhat of the significance of the fact 
that patients suffering from dental infections tend so frequently 
to be underweight, and after the removal of these dental infec- 
tions increase rapidly and materially. In the chapter on Maras- 
mus and in the chapters of Part Two, I review cases with in- 
creases in weight ranging up to 50 per cent, with many of them 
increasing 10 to 25 per cent. This raises the question : To what 
extent is the depression of the weight below normal related to, or 
an expression of, the ionic calcium of the blood? To determine 
this and the associated factors we have made a series of implanta- 
tions under carefully controlled conditions, where the weight has 
been checked carefully against the ionic calcium. A group of 
these is shown in Figure 134, entitled "Chemical Changes in the 
Blood, Produced by Implanting Infected Teeth Subdermally, 
and the Relation of the Changes of Ionic Calcium and Body 
Weight." In this chart we show six rabbits. In the first there 
was a decrease in the ionic calcium of 50 per cent, produced by 
the placing of the patient's tooth beneath the skin of the rabbit, 
and all this occurred in four days' time. There was, accordingly, 
not an opportunity for great wastage of the animal's body, death 
ensuing before the depletion of the tissues. The total loss in 
weight in this case was 17 per cent. In the second case the de- 
crease in ionic calcium was 1.18 grams or 12 per cent. But this 
extended over a period of sixteen days, which gave greater oppor- 
tunity for depletion of the body tissues, the actual loss of weight 
being four hundred seventy-one grams, or 34 per cent. In the 
third rabbit the period taken for the tooth to kill the rabbit was 
shorter — namely, three days — the ionic calcium loss being three 



CHAP. XX CHEMICAL CH VNGES IN BLOOD B^ I >EN I \l l\l Ia HON! 



CHEMICAL CHANGES IN THE BLOOD. PRODUCED BY IMP! ANTING INFE< 1 1 i> l ill II SI BD1 R 
MALLY. AND THE RELATION OF 11 11-: CHANGES OF IONK CALCIUM VND BODY WEIGH! 



Rabbit 

N 


Date 


\\ eight 


\\ eight 1 osa 


Calcium 

plus 
Thrombin 


Calcium 
Ionic 


Calcium 
Ionic plus 


Calcium 

in 
C onibin.it ii hi 


Calcium Ionic 

1 








Actual 


% 








Actual 


'. 


1106 
1106 
1106 


L2 it; 23 
B.2 20 23 
C. 2 20 23 


mi 

942 


199 


17 


11 78 
11 27 
9 80 


10 88 

7 OO 
5 11 


11 7.s 
7 00 
6 09 


ii 'hi 
ii ii 
68 


S »7 


SO 


1145 

1 1 15 
1 1 15 
1145 


\ 27 23 
B.3 28 23 
B3 30 23 
C. I 13 23 


1381 
910 


471 


34 


1 1 50 
13 88 

n; .so 


It) 13 
8 89 
8 95 


10 13 

11 67 
11 23 


n mi 

1 77 

2 28 


1 IS 


12 


1099 A. 2 13 23 

10W B. 2 11 23 

B. 2 1 I 23 

1099 ' B.2 16-23 


1822 
1 183 
L385 


437 


24 


14.80 
13.2 
18 5 
10.19 


11.00 
9 92 

11 22 
7 91 


10.36 

10.82 
9.00 


11 

10 

1 99 


3 09 


28 


1108 
1108 


A 2 20 23 
B. 2 22 23 


1265 
1185 


80 


6 


17.00 
18.40 


10.59 
8 81 


12.61 
13.00 


2 02 

i it; 


1.75 


17 


1109 

1109 


A. 2-20-23 
B.2 22 23 


is:;, 

1256 


119 


9 


17.20 
17.80 


9 88 
7.82 


10.37 
9.80 


0.49 
1.98 


2 06 


21 


I oso 
1080 
1080 
1080 
1080 


A. 1-27-23 
B. 1 L H > 23 
B. 1-31 23 
B.2- 1-23 
B. 2 3 23 


1478 
1360 
1321 

1210 


268 


19 


16.50 
10.17 
7 74 
11.80 
19 00 


8 'to 
7.12 
7.25 
7 99 


8.90 
7 12 
8.69 
8.56 

12.74 


00 

0.00 

1 44 
0.57 


91 


10 



Figure 131 
A — Readings before tooth implantations. 
B— Readings after tooth implantations and before death. 
C— Readings after death. 

grams, and the total loss in body weight four hundred thirty- 
seven grams, or 24 per cent. Similarly, the other three rabbits 
shown in this chart, reveal calcium losses of 17, 21, and 10 per 
cent respectively, with body weight losses of 6, 9, and 19 per cent 
in two days each for the first two and six days for the last. This 
shows clearly that there is a time factor involved, and seems to 
emphasize the profound effect on metabolism, in general, of intro- 
ducing into the animal's body a toxic substance which directly 
disturbs the ionic calcium. The data available do not justify the 
conclusion, however, that no other important factors are directly 
involved, nor that the calcium decrease is the chief or only factor 
interrupting the metabolic process. 

Studies were then made to determine the nature of this calcium 
compound. If it were an insoluble salt it could be removed by 
filtering or centrifugation or settling. It was found, however, not 
to be removed by an ordinary Berkefeld filter or by centrifuga- 
tion. The chemical bond was evidently a very loose one, (though 
enough to take the ionic calcium out of service) since it could be 



258 DENTAL INFECTIONS, ORAL AND SYSTEM IC^RESEARCKES— VOL. I 



again separated with sodium hydrate and the ionic factor of the 
blood serum restored approximately to normal. 

In order further to study this factor, we have injected normal 
rabbits, to determine the effect of various cultures in reducing the 
ionic calcium. These are shown in Figure 135. 

COMPARISON OF CHANGES IN IONIC CALCIUM AND BLOOD MORPHOLOGY, 
DUE TO CULTURE INOCULATIONS 



Date 
1923 


Hemo- 
globin 


Erythro- 
cytes 


Leuco- 
cytes 


Poly- 
morpho- 
nuclears 


Lymphocytes 


Baso- 


Arneth 


Ca and 


Calcium 


Ca Ionic 

and 
Combined 


Calcium 

in 
Combin- 
ation 


Large 


Small 


phils 


Index 


Thrombin 


Ionic 


6-1* 

6-2 

6-4 

6-5 

6-6 


85 
85 
80 
80 
85 


6.900,000 
6,150,000 
5,750,000 
5,800,000 
5.100.000 


15,000 

27,700 
19.800 
16.600 
14,800 


57 
70 1 
35 .5 
64 7 
31 2 


7 
14.4 

8.8 
16 8 

6.4 


34 

15 4 
53 3 
17 9 
62 4 


2 

2.4 


83 

48 


15.20 
17.20 
15 00 
17.00 
17.40 


11 53 

11 80 

9 45 

8 46 
8 05 


13.00 

13.22 

13.66 

8.71 

9 80 


1.47 
1.42 
4.21 
0.25 

1 75 



"Before inoculation. (Case No. 1405. 



Figure 135. 
Rabbit No. 1221.) 



Another research was established to determine further the 
effect of infected human teeth in reducing the normal ionic cal- 
cium of the blood stream, by placing the patient's extracted tooth 
beneath the skin of a rabbit. This has disclosed a very remark- 
able result, as shown in the table in Figure 136. 

This chapter is supposed to deal with chemical changes of the 
blood in relation to dental infections. There are so many ele- 
ments and compounds in the blood that this subject could be 

DEPRESSION OF IONIC CALCIUM BY IMPLANTING INFECTED TEETH 



Case 
No. 


Rabbit 
No. 


Date 


Weight 


Weight 


Loss 


Ionic Calcium 


Pathologically Combined 






Actual 
Loss 


% Loss 




Increase 


Actual 


% 


404 


1118 


3- 5-23 
3- 7-23 


1153 
1140 


13 


1 


11.06 

9 84 


1.22 


11 


0.00 
1.16 


1.16 


1353 


1107 


2-20-23 
2-23-23 
2-26-23 


1069 

1020 

846 


223 


21 


10.76 

11 74 

9 52 


1.24 


11 


2.11 
0.48 
3.92 


1.81 


1371 


1145 


3-27-23 
3-28-23 
3-30-23 


1381 






10 13 

8.89 
8 95 


1.18 


12 


0.00 
1.77 
2.28 


2.28 


1317 


1099 


2-13-23 

2-14-23 
2-14-23 
2-16-23 


1822 

1483 
1385 


437 


24 


11 00 
9.92 

11 22 
7 91 

10 59 

8.84 


3.09 


28 


0.44 
0.40 
1.99 


1.55 


1317 


1108 


2-20-23 
2-22-23 


1265 
1185 


80 


6 


1.75 


17 


2.02 
4.16 


2.14 


1317 


1109 2-20-23 
2-22-23 


1375 
1256 


119 


8 
20 


9.88 
7.82 


2.06 


21 


0.49 

1 . 98 1 49 


1317 


1074 1-17-23 


1925 
1552 


373 


12 37 

6 83 


5.54 


45 


0.64 
0.6 



Figure 136. 



CHAP \\ CHEMICAL CH tNGES IN BLOOD UN DEN I \l INFE< riON 

extended to cover an entire volume. Referring again to Figure 131 
of tins chapter, we find that just as calcium has been a very vari- 
able factor, similarly so have several other substances. It is par- 
ticularly important in the study of these to note their relation to 
each other; and. accordingly, you will note the incidence of a 
hyperglycemia to the calcium factors, total and ionic. It is not 
an accident, in referring back to the composite table, that where 
calcium reads very high the sugar of the blood is very high. We 
have, accordingly, studied the effect of dental infections and the 
relation of the types of dental infection to the different types of 
diabetes. A very important new light has been thrown on the 
whole problem of carbohydrate metabolism and sugar retention 
in the blood by Banting, Best, Collip, Hepburn, and Macleod, 
working at the University of Toronto, to whose work there are 
many references in the current literature. 

It is not necessary to review here that, glycosuria, or the pres- 
ence of sugar in the urine, is not of itself an evidence of hyper- 
glycemia. Formerly, distinction was made between a true and 
false diabetes, the latter being cases in which there was the pres- 
ence of sugar in the urine without serious harm to the patient. 
It is now recognized, particularly due to the work of Hamburger, 
that an increase in ionic calcium in the blood makes it possible 
for the kidney cells to let through a quantity of sugar where little 
or no sugar would pass with the slightly lower ionic calcium. 

While the pathology and etiology of diabetes are not completely 
established, it has been interesting to note that in many cases the 
quantity of sugar in the blood has decreased following the extrac- 
tion of infected teeth, and this disregarding in large part the 
variations and uncertainty of the significance of decrease of the 
sugar in the urine, which is a very common sequence to extractions. 
Such a case is shown as follows: 

The culture grown from the tooth of Case No. 1195, when in- 
oculated into rabbits, raised the blood sugar in nineteen days 
from 97 to 149, which, seven days later, had subsided to 121, and 
in twenty-six days still later to 92, five below the resting normal 
of this rabbit before inoculation. The rabbit was given another 
inoculation of this same culture, which, however, had been re- 
tained in the artificial medium, and on this occasion the same 
dosage increased the blood sugar to 105. This patient's resting 
blood sugar was 130 mgs. per 100 cc. and the urine sugar 430, or 
4.3 per cent. This patient from whom the tooth was extracted 
and whose urine sugar was 430 before the extraction of the tooth, 



260 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

had the same reduced so that on two subsequent determinations, 
(the first one in eleven days,) no sugar was found in the urine, and 
in two years' time, the reports that she has brought to me have 
been that her physician has made frequent determinations and has 
not found sugar. 

One of these patients' blood sugar reduced from 285 to 235 in 
twenty-four hours (probably a temporary change) after the re- 
moval of dental infections. He had no suspicion that he had 
diabetes. When advised to change his mode of living, and par- 
ticularly to put himself under a strict program prescribed by a 
good internist, he advised that his business affairs would not 
allow of any change in his program for some months. This pa- 
tient's urine sugar was 542 mgs., or 5.4 per cent. That this dis- 
turbance was progressive and very serious was evidenced by the 
fact that twenty days later it was 1100, and at this time we again 
urged that he put himself in the care of a skilled internist. It is 
important and pathetic to note that he was buried before that 
time. The importance lies in the fact that people can be in so 
serious condition and not have any knowledge or suspicion of it, 
and again may take the matter with so little concern, depending 
entirely upon their feelings which may be so misleading. 

However, some individuals are capable of carrying a surpris- 
ingly large excess of sugar in the blood for considerable length of 
time. For example, Case No. 1268 has had blood sugar ranging 
from 295 to 410 mgs. per 100 cc, and a urine sugar ranging from 
306 mgs., or 3 per cent, to 446 mgs., or 4>^ per cent, for over a 
year, and while it has materially improved since the removal of a 
number of infected teeth, the glycosuria and polyuria persist. He 
feels so much better that he refuses my urgent recommendation 
that he be placed in the hands of a first class internist for direction 
of his diet. Fortunately, many of these individuals are continu- 
ing into a period when there is more hope for their assistance 
through the use of insulin and other pancreatic preparations. 

Accepting the threshold of probable danger for the human as 
120 mgs. of sugar, after fasting, per 100 cc. of blood, it is quite 
striking to find some sugars in our list going to 400, and, yet, the 
patients were not aware that they had diabetes. These are dis- 
cussed from the clinical standpoint in Chapter 63. We will also 
discuss in Chapter 53 (on theoretical discussion) the significance 
of the type of gingival pathology which accompanies diabetes. 

There is a phase of the role of ionic calcium which must be 
stressed. While the evidence available strongly suggests that 



CHAP. W ( HI MI( \l ( HANG! S IN Bl COD BY DEN l \i INF] ( riONS 26] 

certain rheumatic susceptibilities and conditions tend to develop 
in the presence of a low ionic calcium of the blood, it is equally 
evident that certain types of rheumatism develop in the presence 

of a high ionic calcium. While these seem to be associated with a 
different type of rheumatic symptoms and bone changes, the data 
available do not yet justify an attempt at classification that will 
be expected to be final, though it may be very suggestive. I speak 
of this at this point to forestall hasty conclusions and unwar- 
ranted deductions. In general, we may associate divergences 
from normal in ionic calcium of the blood with general types of 
lesions somewhat as follows: 

Normals tend to have a mean of approximately 10 to 11. Con- 
densing osteitis and lowered defense to rheumatic group infections 
seem generally to be associated with a lowered ionic calcium 
(6.9). A good defense shows a high normal ionic calcium. Active 
periodontoclasias and pyorrhea show an abnormally high ionic 
calcium (10.7-12.5). Individuals with a low ionic calcium do 
not have, while in that state, a tendency to extensive alveolar 
absorption. Patients with large apical areas of absorption have 
a high or normal ionic calcium; patients with relatively small 
apical areas, a low ionic calcium. Individuals whose teeth are 
sore, or have fistulae with recurring inflammatory processes, have 
normal or high calcium; those with low calcium have little or no 
local reaction and evidence, as pain about teeth which are in- 
fected. There are certain associations too: Patients with glyco- 
suria and hyperglycemia, or the latter without the sugar appear- 
ing in the urine, or even those with sugar appearing in the urine 
without its being above the threshold which would term it "True 
Diabetes" tend to have a calcium higher than normal. I have 
discussed these various associations of calcium with the various 
pathological states in succeeding chapters. 

URIC ACID. 

A study of Figure 131 shows a variation in the quantity of 
uric acid present in the blood of the various patients there re- 
corded, ranging from 1 to 7 plus mgs. per 100 cc. Various text- 
books give us a normal of 1 to 3. A study of cases before and 
after removal of dental infections has shown a reduction of uric 
acid following the removal of dental infections. For years an 
important theory as to the etiology of rheumatism has been the 
increased uric acid of the blood. It is, however, now claimed by 
eminent authorities that, while certain of the rheumatoid group 



262 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

of symptoms — namely, gout, — have definite etiological relation 
to uric acid content of the blood, the other types do not have 
this direct relationship and the uric acid factor may vary through 
considerable range either coincidentally or independently. 

ACID-BASE RELATIONSHIPS IN THE BLOOD. 

It has been known for some years that while the hydrogen ion 
concentration of the blood varies but slightly from normal, this 
fact is only possible because of the very efficient buffer system 
contained in the blood, which has made possible quite wide varia- 
tions in acid and alkali production without considerably disturbing 
the actual hydrogen ion concentration. It has similarly been 
known that the C0 2 tension in the alveoli of the lung auto- 
matically controls the rate of respiration, a practical illustration of 
which has been the necessity for a certain amount of re-breathing 
with nitrous oxygen and oxygen in order that the presence of the 
CO, may normally control respiration. In the system carbo- 
hydrates are oxidized at a rate which is determined largely by 
this acid base (or alkali reserve) relationship, which rate is 
directly influenced by hyperfunction of the thyroid. This condi- 
tion of unbalance constitutes an acidosis. This has been deter- 
mined or measured quantitatively by determining the amount of 
oxygen consumed, and of carbon dioxide given off in respiration 
during periods of rest and of fasting for from six to twelve hours. 
We have made a number of determinations on rabbits to ascertain 
if dental infections seriously disturb this basal metabolic rate, 
the animals being placed within the chamber connected with the 
metabolism machine. We have developed important data by this 
method but have found it a very laborious and tedious one. 
Several factors enter into this determination which cannot be 
controlled in rabbits as they can in the human. If the particular 
animal under study has been used to being handled and watched, 
the problem of excitability and fear will be reduced to a minimum, 
whereas in other animals, either because of lack of handling or a 
normal instinct of alarm and fear, these elements will completely 
change its rate of breathing and therefore its metabolic rate. 
That this is true is evidenced by the considerable variation in the 
readings that may be gotten with a given rabbit under different 
conditions of excitement. Another method — namely, that of 
directly reading the Ph with a potentiometer — is also very tedious 
because of the involved difficulties in maintaining the same C0 2 
tension as obtained in the drawn blood, which cannot be allowed 
to come in contact with air, or be breathed upon by the operator. 



CHAP. XX CHEMK \l CHANGES IN BLOOD B^ DENTAL INFE< riONS 

The discussion of the acid-base balance and alkali reserve will be 
uuind in Chapter 1 1. Calcium and Acid-Alkali Balance. 

SI MM \KY AND CONCU'SIONS. 

From these data it is apparent that very important chemical 
changes arc produced in the blood from dental infections, and 
such as are far-reaching in the processes of metabolism and func- 
tion. One of the very conspicuous changes is the disturbance of 
ionic calcium and the presence in the blood of a pathologically 
combined calcium. Since cell activity, both metabolic and cata- 
bolic, is dependent largely upon a normal ionic calcium in the 
fluids at the cell boundaries, very minute changes may produce 
very important physical disturbances, as, for example, the kid- 
neys' permitting sugar to pass through when the ionic calcium 
gets above the normal limits. We would summarize some of the 
important chemical changes briefly as follows: 

1 1) Dental fecal infections tend in many instances to lower the 
ionic calcium of the blood. (The fact and significance of a high 
ionic calcium in periodontoclasia are discussed in Chapters 45 
to 56.) 

2 1 The placing of certain infected teeth in the blood serum of 
patients suffering from certain rheumatic group disturbances 
tends markedly to lower the ionic calcium of that serum. 

( 3 ) There is frequently found in the blood of individuals suffer- 
ing from rheumatic group lesions, a reduced ionic calcium state 
and also a measurable pathologically combined calcium, which 
progressively disappears after a patient returns to normal. 

(4) The placing of a patient's infected tooth beneath the skin 
of a rabbit tends similarly to reduce the ionic calcium of its 
blood. (The relation of these to the endocrine system is dis- 
cussed in that chapter, No. 37.) 

(5) Injection into the circulation of animals of the organisms 
grown from the teeth which produce these changes in the blood, 
tends also to reduce the ionic calcium of the animal's blood. 

(6) The presence of dental infections tends in many instances 
to change the alkali reserve of the blood of patients; and when 
these teeth are placed under the skins of rabbits, they tend also to 
change their alkali reserve. 

(7) Dental infections in some instances change the blood sugar 
content of the patient, as evidenced by the return to normal after 
the removal of dental infections, and the increase in blood sugar 
in animals, by injecting them with the culture from such teeth. 



264 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

(8) The uric acid content of the blood varies considerably with 
the presence or absence of dental infections, particularly in cases 
of gout. It may, however, be very slightly changed in many 
cases of definite rheumatic group lesions, and its variation in the 
blood is very closely paralleled by its presence in the saliva. 
Dental focal infections tend to produce, in many 
instances, one or several chemical changes in the 
blood, which changes tend also to be produced in 
animals when an infected tooth is placed beneath 
its skin; and, similarly, with certain methods of 
inoculation with the culture grown from these 
teeth. Some of the changes most frequently found 
involve : 

(a) The ionic calcium of the blood. 

(b) The presence of a pathologically combined 
quantity of calcium in the blood. 

(c) A reduction of the alkali reserve of the blood. 

(d) The development of acidosis. 

(e) An increase in the blood sugar. 

(f) An increase in the uric acid. 

(g) The development of nitrogen retention. 

(h) The development of products of imperfect 
oxidation. 



CHAPTER XXI. 

CONTRIBUTING OVERLOADS WHICH MODIFY 
DEFENSIVE FACTORS. 

PROBLEM: What are the contributing factors causing 
a break in resistance? 

EXPERIMENTAL AND DISCUSSION. 

We have looked upon dental infections as being sufficient or 
insufficient to produce the disturbances under consideration. 
This series of studies has been made to ascertain what, if any, are 
the factors which may be associated with dental infections and 
produce, or aid in producing, the break in resistance which ex- 
presses itself in systemic, as well as local disturbance. In a 
previous chapter, No. 4, we studied the basis on which human 
beings are comparable and found that, in the main, they may be 
divided into three groups with regard to their susceptibility to 
rheumatic group infections: namely, absent susceptibility, ac- 
quired susceptibility, and inherited susceptibility. In this chap- 
ter we desire to study the contributing factors to susceptibility 
by modifying the defense of the individual. These, we find, 
naturally divide themselves into two groups: namely, those 
which tend to make people with a normally high defense become 
susceptible in some tissue; in other words, changing a person 
from an absent susceptibility to an acquired susceptibility classi- 
fication; and second, the forces which control in a case of in- 
herited susceptibility and tend to make some particular tissue 
susceptible in that family. 

An analysis of our collected data reveals that a very large 
number of individuals develop their rheumatic group lesions 
either as a complication with influenza or quite early following it. 
This will include not only rheumatic group lesions, more strictly 
speaking, but also bacterial invasions of other types such as 
tuberculosis and pneumonia. This latter, however, probably 
should, under these circumstances, often be considered as a rheu- 
matic group lesion since it is often a systemic expression of 
streptococcal involvement already focal in the body. To de- 
termine this more exactly, I made a very careful study of in- 

265 



266 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES- VOL. I 

fluenza patients in five hospitals, three in this city and two in 
Columbus, in the epidemic of 1918. This was an exceedingly 
difficult study to make for several reasons: First, the patients 
involved were frequently too ill to be questioned with sufficient 
care to bring out all the data; and second, it was not possible to 
make roentgenographic studies, and many cases of dental 
infections were undoubtedly overlooked since only those 
were included, which were sufficiently gross to be determined 
definitely by oral examination, palpation, etc. A study of two 
hundred sixty influenza patients in five different hospitals, Fig- 
ure 137, disclosed that when the patients were divided into two 
groups — those with, and those without clearly demonstrable 
dental infections — the percentage of individuals developing 
serious complications (in which we included pneumonia, empy- 
ema, carditis, severe neuritis and severe rheumatism) was found 
to be in the group without dental infections 32 per cent, and in 
the group with serious dental infections 72 per cent. Several 
factors should be carefully noted: In the pneumonias, the tend- 
ency to strangulation following coughing spasms, as a result of 
the bronchial exudate, produced violent inspirations which draw 
into the lung, fluids and infections from the mouth. This makes 
gingival infections a very marked contributing factor to the de- 
velopment of pneumonia. In general, however, the so-called 
locked infections (by which we mean those at root apices without 
opportunity for drainage into the oral cavity, which therefore must 
drain into the system, into the lymphatic and hematogenous 
circulations) are more to be feared since the system must of 
necessity become invaded from this source, with a breaking 
down of the local defense which has tended to wall off and defend 
the patients in times of their normal defense. 

In our studies of this series we have found that, in the patients 
who have kept their mouths in good condition, free from gingival 
and apical sources of infection, both the incident of influenza it- 
self, and complications with the influenza, are much lower than 
in the patients with extensive dental infection. This fact has l 
also been reported to me by other dentists. 

These general observations, together with the observations 
made in private practice, seem to demonstrate that the individ- 
uals, who carry focal dental infections with apparent safety dur- 
ing the period of their normal health, immediately are endangered, 
and very seriously so, when they are attacked with influenza 



CHAP. XXI CONTRIBUTING OVERLOADS fO DEFENSI\ E F U fORS 



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268 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

infection. In order further to test this problem, I have in the 
succeeding epidemics made inoculations into the tracheae of 
rabbits of the washings of the nasopharynges of the Flu patients, 
and have made comparative tests to determine whether or not 
these rabbits were more susceptible to focal infection. Figure 138, 
lower view, shows a reproduction in natural color of the lungs 
of a rabbit dying from pneumonia, as illustrating this condition. 
A rabbit was inoculated intratracheally with the washings from 
the nasopharynx of a Flu patient during the first twelve hours 
after the attack. This rabbit showed a depression in its mononu- 
clear blood cells, typical of the influenza involvement, and was 
less active following the injection, with loss of appetite. (Rabbits 
so inoculated recover in a few days.) It was killed, and its lungs 
removed and macerated in normal salt solution, which washing 
was injected intratracheally into other rabbits. These developed 
the same general symptoms. The lungs of this rabbit are shown 
in Figure 138, upper view. Of the two injected intravenously with 
small quantities, y 2 cc. of a 24-hour culture from dental infection, 
this one died of pneumonia (Figure 138, lower view). This experi- 
ment was made in the epidemic of February, 1923. A similar 
observation was made in the epidemic of 1922. A rabbit was 
injected intratracheally with the washings from the nasopharynx 
of a patient suffering from influenza, followed by the intravenous 
injection of a dental culture. This rabbit developed typical 
streptococcal pneumonia. A section of the lung is shown in 
Figure 139. Similarly, we have found that, when infected teeth 
are planted beneath the skins of the rabbits, they sometimes 
develop acute and terminal pneumonia. (See Chapter 61.) 

PREGNANCY. 

An analysis of the sex in Figures 42 and 47 in Chapter 4, reveals 
that the increase in the prevalence and severity of rheumatic 
group lesions shows a continued increase toward the female sex. 
A further analysis of these data reveals that in a great many in- 
stances, the acute attack of rheumatism dates directly to the 
time of pregnancy and lactation. The usual age of first rheu- 
matic group involvement is between twenty and thirty-five in 
females. 

Since so many young mothers, or expectant mothers, have de- 
veloped acute rheumatism, heart, or other rheumatic group 
lesions, during the period of gestation or lactation, we have come 
to recognize this as one of the most important overloads which 




Figure 138-A. Influenza Lung of a Rabbit inoculated intratracheally with 

NASAL WASHING FROM A FLU PATIENT. THIS IS NOT FATAL TO RABBITS. 



I 



s 







Figure 138-B. Fatal Streptococcal Pneumonia from injecting 

DENTAL CULTURE INTRAVENOUSLY INTO RABBIT WITH INFLUENZA. 

269 



CHAP \\l C0NTRIB1 HNG OVERLOADS fO DEFENSIVE FA< TORS 1*71 




Figure 139. Shows a section of the lung of a rabbit which died of 
streptococcal pneumonia from a dental culture. the bronchioles are 
obstructed by the thickening of their lining membranes and by the 
emphysema. 



we have to consider. To illustrate: 

A young married woman of twenty-two years undertook the 
responsibilities of motherhood with a physique and physical re- 
serve which would be expected to be well above the average. In 
childhood she had had a mild endocarditis which left a mitral 
leakage. She also suffered from acute rheumatism, having had 
two quite acute attacks. After the birth of her babe, which was 
unusually robust, and during the early period of lactation, she 
developed such severe rheumatism that she could not wait on 
herself or the baby. A couple of infected teeth were removed 
and she immediately improved, though her relief was not com- 
plete. She ceased nursing her child in about six months, and 
immediately her remaining rheumatism disappeared. During 
the time of lactation she had been drinking large quantities of 
good milk. 

We have seen this clinical picture over and over, and decided 
to make a test on rabbits. Accordingly, the following experiment 



272 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

was made. A rabbit referred to in Chapter No. 66, which had 
developed a corrplete paralysis posterior to the first lumbar 
vertebra, with loss of continence of urine and faeces, and com- 
plete loss of all sensory and motor control of the posterior region, 
and which had recovered so completely as to be apparently 
normal, except for a slight atrophy of a few groups of muscles, 
which caused a rotation of one hind leg, as shown in illustration, 
and which had gained in weight from 1025 grams to 1600 grams, 
was tested for the effect of maternity on its resistance to the 
residual infection. The roentgenograms showed both the loca- 
tion of the lesion and its structural change. The rabbit itself is 
shown in Figure 140, the roentgenogram of the spine in Figure 
141, and a section of the repaired lesion about nine months after 
the original inoculation and the first development of the lesion of 
the spine. At the beginning of gestation, this rabbit was ap- 
parently in exceedingly good physical condition. It was fat, its 
coat sleek, and in every way seemed normal. It went through 
term with apparently no untoward symptoms. Five young were 
born, which seemed, at birth, to be developed normally. They 
all died in from a few hours to one and one-half days. She did 
not have the continued overload, therefore, of lactation. Prior 
to their birth and following, she was observed to be very nervous, 
easily frightened, and excitable. Her nervousness increased in 
severity and she began losing in weight, finally developing a very 
marked disturbance of the central nervous system, with choreic 
motions, rotation of the head with the least excitement, and she 
became so nervous that if the hands were clapped very hard near 
her, she would fall over on her side. She died in about five weeks' 
time with a terminal pneumonia which, on culturing, showed a 
streptococcus and diplococcus similar to that found in the lesions 
and similar to the organism injected, and originally secured from 
a tooth. Under another chapter, we will speak of pregnancy 
complications. It is my opinion that the lesion in the spine, 
though healed, retained the same type of infection which had 
originally been injected into the rabbit and which produced the 
spine lesion; that, at the time of lowered resistance, this organism 
about which Nature had been able to build a barrier, became 
rampant, again affecting first the overloaded nervous system, 
and later became focal as pneumonia. 




Figure 140. A rabbit in which < uci dfrom rHE center of the spine backward, 

BY DENTAL CULTURl IN. I T APPARENTLY RE( i COMPLETELY EXCEPT FOR ATROPHY OF A FEW 

MUSCLES WHICH PRODUCED A TWISTED LLC. 



273 





Figure 141. Views and sections of the spine of rabbit shown in Figure 140. Note destruction of 
intra- vertebral cartilage in a and b; destruction of body of vertebra in c; and mild condensing 
osteitis in d and e. 



274 



CHAP. XXI C0NTRIB1 HNG OVERLOADS IX) DEFENSIVE FA< TORS 275 

TRAUMA. 

Acute irritations producing an active inflammatory process 
would seem to increase, or at least not reduce, the local defense 
of most tissues; whereas, a continued irritation tends to reduce 
the resistance of the tissue involved and make it more susceptible 
to infective invasion. To illustrate: 

A man who had been on shipboard in passage from the Philip- 
pines to this country, following which he was on the train from 
San Francisco to Cleveland, all of the time without much exer- 
cise, secured a position as floor walker or night watchman in a 
manufacturing plant, having acres of cement floors, requiring 
several miles of walking for his beat to ring in the record of his 
rounds. He wore shoes without rubber heels. The irritation to 
the synovial membranes at first gave him a sense of discomfort, 
which was relieved by resting. After continuing the irritation 
for a few weeks, he w T as afflicted with acute rheumatism in the 
joints receiving the thrust. During all of this time he had had 
chronic dental infections. The removal of the dental infections, 
together with the use of rubber heels, relieved the synovitis and 
he was able to continue in the same occupation. 

Similarly, eye strain makes the eyes much more susceptible to 
irritation from dental infection. Figure 6, Chapter 1, illustrates 
the dental condition of a patient who had such a disturbance. 
He had suffered for several years from the difficulty of not being 
able to read for long periods, a condition which was helped by 
periods of rest but not entirely relieved. It was also helped, but 
not relieved, by glasses. The removal of his dental infections 
made it possible for him to discard his glasses which he had worn 
for fifteen years, and made it possible for him to read without 
limit and without discomfort. We have had many cases where 
the patients have reported to us, after the removal of their dental 
infections, that they did not longer need to use their glasses. 

GRIEF AND WORRY. 

Similarly, an overload of mental strain makes individuals 
more susceptible to dental infection. Probably no contributing 
factor so greatly lowers the defense, unless it be an influenzal in- 
fection, as the mental condition in grief or anxiety. To illustrate : 

A family of five girls nursed their father through a long illness, 
terminating in death from pernicious anemia, which was followed 
by a severe illness of the mother and final death from heart in- 
volvement. These girls were not physically exhausted from nurs- 



276 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

ing duties, but were nearly prostrated by grief. All developed 
rheumatic group lesions such as neuritis, and two had heart in- 
volvements. The conditions were very markedly improved, and 
the neuritic symptoms relieved by the removal of dental infec- 
tions. 

An experiment was made to determine the effect of worry. 
Two ferrets were secured and put into a compartment within a 
rabbit's cage. At first the rabbits seemed very fearful of them 
but as soon as they learned that the ferrets could not hurt them, 
they entirely ignored their presence. Results of this test were 
negative. 

EXPOSURE. 

Physical exposure is probably one of the most serious and most 
common of the overloads which come upon the human body to 
lower its defense and make it a prey to the focal infections 
against which it has, under normal conditions, an ample defense. 
In Chapter 64 on acute rheumatism, I give the history of a case of 
a man who was a partial invalid from a form of neuritis for over 
twenty years, following exposure, repairing a burst water main 
in the winter, which threatened to do great damage to the factory 
in which it happened. This man worked in the nearly ice-cold 
water for about two hours repairing the break. At the time of 
this exposure, and for a year preceding, he was having dental 
work done, including the treating of several infected teeth. His 
neuritis was so severe that it drew his knees nearly to his chin for 
many weeks, and one arm was almost useless from atrophy. 

To test this we have made cultures from the teeth of a patient 
suffering from rheumatism and have made inoculations into four 
rabbits, two of which were used as controls, kept in a warm cage, 
and received the same inoculations as the two being tested, which 
latter were submitted every day or two to exposure of cold, by 
having their hind legs immersed in water with broken ice in it. 
The dosage in these cases was purposely small. The control 
rabbits received twelve inoculations within a period of thirty-two 
days. The two exposed to the chilling received the same inocula- 
tions on the same days. All of the rabbits lost in weight following 
the inoculations. The average loss of weight of the two that were 
not exposed to the chilling was 10 per cent, and of the two that 
were exposed was 14 per cent. But this is not the most important 
effect of the exposure. The two that were not exposed did not 
develop any lesions from the inoculations. One is still living four 




■ 




A 





\ 



B 






Figure 142. A and B show twi i r ^bbits which developed acute suppurative arthritis from small 

INJECTIONS OF DENTAL CULTURE, PUS CHILLING IN COLD WATER. THE TWO CONTROLS RECEIVING THE SAME 
CULTURE BUT NOT CHILLED DEVELOPED NO LESIONS. 

277 



278 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

months after inoculation, has gained in weight to 241 grams. 
The other has recently been used for another experiment, it hav- 
ing gained considerably in weight following its last inoculation. 
The two that received the chilling, however, developed very severe 
rheumatic lesions, both of which are illustrated in Figure 142, 
A and B. A shows an extensive intracapsular abscess of the left 
shoulder, extending into the muscle sheath. B shows a sub- 
cutaneous multiple suppurative arthritis of the right shoulder 
and the left wrist and third and fourth digits. 

We have here an illustration of what happens when an indi- 
vidual with an infected tooth is exposed to severe chilling. Dur- 
ing the period of normal exposure he may have a loss in weight 
and some depression and injury, expressing itself chiefly as lassi- 
tude or marasmus, or both; but on exposure to cold or other de- 
pressant, the resistance of the tissue is seriously lowered, the 
total defense of the body goes down, and the rheumatic lesions 
appear, which may be rheumatism, neuritis, or functional dis- 
turbances of special organs, as was illustrated by the case of the 
man chilled in repairing the burst water main. 

There is a phase of this problem of exposure which is very ob- 
scure and involved. We have all seen individuals who would 
remind us that their joints felt like rain, which seemed clearly to 
indicate, since they were so often correct, that their biological 
mechanisms were responding to changes of humidity and atmos- 
pheric pressure. Our researches recorded in the preceding chap- 
ters have strongly indicated that whatever other factors are 
largely variable, of which doubtless there are many, the ionic 
calcium is apparently very important. We have found, as 
shown in Chapter 20, that the presence of focal streptococcal 
infection tends to reduce the ionic calcium of the blood through- 
out the entire circulation, and very markedly so when the tooth 
is placed directly in the serum of freshly drawn blood for a couple 
of hours. If, then, these individuals have their ionic calcium 
reduced to, or nearly to, the threshold, we can readily understand 
that a local depression of some part of the body by chilling, 
might throw the calcium content below the threshold at that 
point. Accordingly, if the patient sits in a draft when he or she 
has an infected tooth, the circulation ionic calcium being near the 
threshold, that of the back of the neck where the draft strikes is 
sent below that point. That tissue, then, has lost, temporarily, 
its reserve defense; it is a prey to the toxic invasion passing 



CHAP. XXI C0NTRIB1 HNG OVERLOADS n> DEFENSIVE FA< IX)RS 27!) 

through the system, and more or Less severe symptoms from a 
mild myositis to a muscle spasm with torticollis are the result ; or 
there may be neuritis of the cervical nerves. The problem of 
tissue temperature has also a very direct effect on susceptibility 

and defense. 

Two things are most logical as a treatment: First, to remove 
the source of infection after it can be found, (not that all toxic 
irritations come from dental infections or even all from focal in- 
fections) and to raise the defense of this local tissue by both the 
application of heat and the liberation into the fluids of the in- 
volved tissue of ionic calcium through the process of massage. 
To test the first of these we have very many times, as recorded in 
subsequent chapters on the pathology of systemic dental infec- 
tions, completely relieved these symptoms permanently or for 
years by the removal of dental foci, though they had been coming 
with very great frequency. To determine the form of different 
mechanisms that are operative in the process of massage of vari- 
ous types, we have made determinations of the ionic calcium of 
the blood in a given tissue, say a rabbit's ear, and then massaged 
the rabbit's ear first lightly and made determinations, then 
vigorously, and finally very vigorously, and have found that 
mechanical irritation of the tissue slightly changes the ionic 
calcium of the blood from that tissue. 

It is a question whether the osteopaths will ever appreciate, 
and it is to be hoped the laity never will, how much that group is 
indebted to the dental profession for the preparation of a group of 
patients with an affection that will keep them coming; and we 
trust that the gratitude of the patients who have had these suc- 
cessive treatments made unnecessary, will adequately offset the 
curtailment of the visits to the physical therapists which will 
result from a final intelligent removal of dental foci. 

In the chapter on sensitizations we discuss not only anaphyl- 
axis as an antigen-antibody reaction, but also the phenomenon of 
local tissue sensitization, which it is probable are important 
factors in the development of this infinitely sensitive mechanism 
which makes it possible for the grandmothers and grandfathers 
and some not yet graduated into that class, to be such efficient 
weather prophets. 

NUTRITION AND HUNGER. 

Since every machine is dependent upon its supply of fuel if it is 
to maintain its output of energy, the human body is dependent 



280 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

upon the nature and quantity of its food supply. In the chapter 
on nutrition we discuss this definitely from that viewpoint, for 
few, if any, of the overloads of the human body will so often be 
found to be a contributing factor as will faulty nutrition. In 
this chapter we are discussing the relation of overloads to dental 
focal infections. There are, accordingly, two distinct methods by 
which this occurs. The individual who is hungry is more sus- 
ceptible to infection of any kind. For years it has been the teach- 
ing, in medicine, that no man should go into the presence of con- 
tagion, hungry or with an empty stomach, because his defense 
would be lowered. The reasons for this are most apparent. 
Without an adequate fuel in the furnace, the generation of heat is 
diminished and the temperature of the dwelling decreases. The 
chemical processes of the body are practically all increased with 
an increase of temperature, with each increase of which, above 
normal, the reactions of the body are increased approximately 
ten per cent; and, similarly, with each decrease of which, the 
reactions are reduced approximately a similar amount. This is a 
fundamental factor in the problem of exposure to which we 
referred in a previous paragraph. 

But there is another important method by which nutrition 
directly acts upon the process of defense. Metabolic processes, 
and particularly calcium metabolism, are dependent upon certain 
chemical substances, the nature of which we do not yet under- 
stand, which are derived from various glandular tissues of the 
body, generally referred to as the glands of internal secretion, and 
upon certain substances spoken of as accessory food factors or 
vitamines, a certain quantity of which will be necessary for meta- 
bolic and catabolic processes. The quantity factor of these is, 
incidentally, small and is discussed in the chapter on nutrition. 

EXHAUSTION, PHYSICAL AND NERVOUS. 

It has long been said that work never kills but worry does. It 
is exceedingly difficult to determine what are the chief factors in- 
volved in exhaustion, partial or complete; that is, whether the 
fatigue is chiefly a quality of the musculature or of the nervous 
system. Our clinical experience reveals many cases where partial 
exhaustion, or long continued overload of work, seems to contrib- 
ute very directly to increasing the susceptibility to focal infec- 
tions. It is exceedingly difficult in any clinical case to eliminate 
such factors as worry, lack of nutrition, exposure, etc. Because of 
this difficulty to exclude all other contributing factors, it seems 
unsafe to quote clinical cases. 



CHAP XX] CONTRIBUTING OVERLOADS TO DEFENSIVE FACTORS 281 
u I IK AND CHRONIC INFECTIONS. 

It seems probable that any disturbance, whether physical or 
infectious, tends to disturb the normal defensive factors of the 
body. A very common overload of an infectious nature, but 
fortunately much less common than previously, is typhoid fever. 

We find in our case histories that main - patients have their first 
attack of acute or chronic rheumatism accompanying or following 
typhoid fever. To what extent these patients would have been 
involved had they not had focal streptococcal infection is, of 
course, impossible to state. The following seems to be a typical 
history of some of these cases. 

About thirty years ago this patient had typhoid fever at the 
age of about twenty. Immediately following her typhoid, she 
developed acute rheumatism with progressive arthritis defor- 
mans. I have watched her case for twenty-eight years, during 
most of which time it became progressively worse until she was 
entirely unable to walk. I sent for her six years ago in order that 
I might remove some teeth that I had crowned twenty years 
previously. The removal of these dental infections not only 
prevented the condition from becoming progressively worse, as it 
had been advancing, but since that time it has become progres- 
sively better. It seems very probable that the acute onset was 
largely due to her broken defense, and its attending disturbances 
of nutrition, etc., occasioned by her typhoid infection. 

SYPHILIS. 

In discussing the role of another infection as being contribu- 
tory, the matter becomes much more complicated when we con- 
sider an organism which, of itself, is able to produce lesions which 
may be comparable to those produced by the injected strepto- 
cocci. It is, however, a frequent observation that patients pre- 
senting with involvements of the nervous system and at the same 
time carrying a dental focal infection, seem to be more suscep- 
tible to their dental infections than normal. 

The two types of nerve reactions are sufficiently different to 
be differentiated, even when present at the same time in the same 
patient. The streptococcal involvements are acute and recessive, 
the recurrences and exacerbations being characteristic in that 
they are relieved by salicylates, and are improved by massage. 
On the contrary, the syphilitic disturbances are more persistent 
and continuously progressive without the marked exacerbations 
and recessions that accompany streptococcal involvements. The 



282 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

removal of the dental foci will often relieve permanently these 
typical rheumatic type disturbances, while the less variable and 
progressive symptoms of the syphilitic infection will not be 
relieved by the removal of the dental foci. In a later communica- 
tion I will discuss the means for differentiating, and the fre- 
quency of the presentation of lesions, which are thought to be 
rheumatic of streptococcal origin, but prove to be syphilitic 
processes. In a later communication I will discuss the need for 
careful differential diagnosis between streptococcal focal infection 
reactions as rheumatism, particularly of the knees, and rheumatic 
disturbances of very similar nature of gonorrheal origin. 

ALCOHOL. 

It is not strange that alcoholics are more susceptible to strepto- 
coccal infection from focal dental infection or other source than 
normal. Any substance which, when taken into the system, dis- 
turbs cell function would be expected to disturb defense. This is 
a very common clinical experience. 

SUMMARY AND CONCLUSIONS. 

The individuals constituting the members of the group we 
have designated as having an acquired susceptibility, have in 
large part come into that group as the result of overloads plus 
focal infection. It is probably not fair to speak of old age as an 
overload. It is, however, true that much less increase above 
normal constitutes a potential overload for the aged than the 
middle-aged; and, similarly, of the middle-aged than over the 
vigorous young. 

The overload that we have most frequently found to have been 
the cause of transferring an individual from the group of absent 
susceptibility to acquired susceptibility is influenza. And in this 
connection it is significant that statistics that have been accumu- 
lated in England and Wales have shown that in the two years 
following the epidemic of Flu, approximately four times as many 
individuals died from the complications following and incidental 
to Flu as did from the Flu attacks. Our own studies have also 
shown that the prevalence of grave complications with influenza 
is two and one-third times as great in the group of individuals 
having dental infections, as in the group free from dental infec- 
tions. It now seems evident from these and our inoculations on 
animals, that focal dental infections are a potential danger, be- 
cause of the complications arising from them incidental to an 
attack of Flu, of far greater seriousness and importance than has 



CHAP Wi CONTRIBUTING OVERLOADS TO DEFENSIVE FACTORS 283 

been realized. Such an individual is carrying a potential charge 
of dynamite which may, when least expected, explode and in- 
volve his system and gravely endanger his life, for, of the individ- 
uals with complications whom we have found in the hospitals, 
thirty to fifty per cent died. 

We have alluded to the fact that, whereas the percentage of 
males and females in the group which we designate as non-sus- 
ceptible, is approximately equal, the percentage of females to 
males rapidly increases in direct proportion to the severity of the 
susceptibility, changing from fifty-fifty in the absent suscepti- 
bility to ninety-three per cent of females in the strongly inherited 
group to seven per cent of males. Our studies have shown that 
this change in ratio is largely the result of the increase of over- 
loads induced by motherhood. Pregnancy is, therefore, one of 
the most important overloads which must be reckoned with, and 
prepared for, to which the human body can be subjected. 

Similarly, overload of tissues such as physical injury, extreme 
anxiety, exposure, nutrition and hunger, exhaustion, physical 
and nervous, acute and chronic infections, syphilis, and alcohol, 
all contribute singly or collectively to breaking an otherwise 
ample defense. The individual without the dental infection, 
would suffer depression or exhaustion, from which he would 
readily recover, but with the presence of focal infection, finds 
himself the victim of an enemy he does not recognize and cannot 
reach. He breaks in some of the special tissues, frequently the 
one that has been overloaded or exposed. The tendency has been 
to treat the symptom, and it has often taken long periods of time 
for the patient with forced rest and every effort to reduce the 
overloads, to regain the mastery of his focal infection. Our clin- 
ical experience is that scores of these people go right on with their 
overloads, with complete relief from their physical symptoms due 
to the infections, when the dental infections or other focal infec- 
tions are removed, showing clearly that the primary disturbance 
has been the infection. The individual has proved to have ample 
strength to carry his normal physical burden if relieved of his 
focal dental infection, which latter will often be sapping his 
system of more of his vitality and nerve energy than will his 
entire physical and nervous energy combined. 

We would briefly summarize by saying that the individual 
with an absent susceptibility to rheumatic group lesions, is in a 
condition of only relative safety, for at any moment that his 



284 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

overloads of age, physical and nervous expenditure, exposure and 
grief, contributing infections, shall singly or in combination lower 
his total defense, he will become a prey to that dental infection 
which will attack his weakest link, which in these cases of an 
acquired susceptibility, whether in part or in combination with a 
mild heredity, will tend to be the most susceptible tissue, and 
most frequently the nervous system. 

Dental infections, while potentially harmful, 
may not be causing apparent or serious injury until 
the individual is subjected to some other overload, 
at which time a serious break may come. The 
chief contributing overloads are influenza, preg- 
nancy, lactation, malnutrition, exposure, grief, 
worry, fear, heredity, and age. 



CHAPTER XXII. 

I I IX fl\ E LOCALIZATION AM) TISSUE AND ORGAN 
SUSCEPTIBILITY PHENOMENA. 

PROBLEM: Do the organisms of dental infections 
possess or acquire tissue affinity and elective localization 
qualitu s- 

EXPERIMENTAL AND DISCUSSION. 

Seldom in the history of any problem in medicine has the 
storm centered around a single individual as it has, in this in- 
stance, around the pioneer worker and chief advocate of elective 
localization on the part of streptococci, Dr. E. C. Rosenow; and 
few, if any. of the contributions to medicine of the last two 
decades are likely to promise so great helpfulness to humanity, as 
the development of the relationships of focal infections to the 
degenerative diseases. The antagonism and opposition have 
grown out of a lack of knowledge of the mechanisms constituting 
the attacking forces of the invading organisms, and of the defen- 
sive forces of the hosts. (The bibliography of this discussion 
would cover hundreds of pages of references and would not be 
necessary or appropriate here.) 

Probably no problem in connection with this most complicated 
group of pathological processes is so complicated and so certain 
to be misunderstood by many who read as will this phase. To 
many people there will be little difference at first thought between 
elective localization, and organ and tissue susceptibility, notwith- 
standing they are very different, since the former pertains to 
qualities which relate exclusively to the bacterium, and the latter 
to qualities which relate exclusively to the invaded special tissues. 
These are so distinct that they should be discussed in two separate 
chapters. Yet we have combined them in order to emphasize the 
need for their differentiation by specific reference made continually 
through this discussion. 

There is another reason why the discussion of this subject is 
unusually difficult: namely, the prejudice amounting to almost 
unalterable convictions in two groups, one of which has main- 
tained, that elective localizations should not be anticipated be- 

285 



286 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

cause of evidence developing from experimental data. Some of 
the disbelievers have tried and it did not work; therefore, it is not 
so. 

A review of the elective localizations resulting from inoculation 
of a thousand rabbits with cultures taken from dental infections 
of various types, with and without acute processes on the part of 
the patient, but generally with, should, according to the claims of 
the extremists, prove or disprove whether it is possible for bac- 
teria to carry into animals an elective localization quality cor- 
responding with the lesion of the host from whom the tooth was 
extracted. 

A study of any successive thousand inoculations would neces- 
sarily include so many different varieties of problems that the 
data would not all be directly related to this particular phase of 
elective localization. Instead, then, of making our specific 
studies of the quality of elective localization as an inherent prop- 
erty of the microbe, we have taken groups of inoculations from 
individuals with, and without acute processes in various tissues of 
their bodies, and in whose cases the organisms had been taken 
from the teeth, and after culturing by comparable methods had 
been inoculated in comparable doses into animals by comparable 
methods. Results of these studies and comparisons are more 
instructive than could be a miscellaneous group of inoculations 
made under dissimilar conditions and by methods that were not 
comparable. 

In the first place, this group of experiments includes all types 
of studies, many of which were not even indirectly related to dis- 
covering the qualities implied in elective localization. In fact it 
includes, in many cases, experiments made to demonstrate that 
elective localization would not take place under the conditions of 
the experiment. There are so many factors involved which, as 
yet, even those best informed from intensive study do not under- 
stand, that no group of figures can be considered conclusive. To 
illustrate : 

Few animals were considered more susceptible or more certain 
of death from inoculation of the anthrax bacillus than the guinea- 
pig; and, yet, it is now demonstrated by Besredka and Noetzel" 
that, if the guinea-pig could exist without its skin, it would be 
entirely immune to anthrax; that it can be injected with lethal 
doses into the blood stream or peritoneal cavity without serious 

12 See bibliography. 



CHAP. XXII ELECTIVE LOCAJ IZATION AND ORGAN SUSCEPTIBILITY 287 

injury, but the most extreme care must be taken, not to permit 
one organism to reach the skin. Ii, then, two experimenters 

undertake to test whether or not the anthrax organism will kill 
guinea-pigs, without a knowledge of this fact, one individual may 
prove conclusively that the animal is immune because his technic 
is actually different, though apparently the same, in the matter 
of contamination of the skin with the organism in the process of 
inoculation. 

The attitude of mind on this question can be illustrated by the 
following experience of the writer. I received a letter from a man 
in another state, stating that he was sending, under separate 
cover, some teeth that he had extracted from a patient, and that 
he desired to test whether or not there was any truth in the theory 
of elective localization by having me inoculate rabbits and de- 
velop in them the lesions, and report the lesions to him; and, if 
they were the same as those suffered by his patient, of which, of 
course, I was not informed, he would believe in the theory; and, 
if not, it would be proof to the profession that there was no truth 
in the theory. The teeth arrived after many days in a dry condi- 
tion in a pasteboard box, overgrown with a mold, probably con- 
tamination. Of course, this is not comparable to that of the just 
critics of elective localization ; and we have desired to keep ourselves 
free from opinion and prejudice for either side of the argument in 
conducting these studies. 

The following experiment was made to throw light upon the 
question of the influence of the culture medium upon the quality 
of elective localization, if such resided in the organism. A cul- 
ture was made from the live but infected pulp of a tooth of a boy 
nine years old who was suffering from an acute endocarditis and 
acute rheumatism with very severe symptoms. Thirty rabbits 
were inoculated in the first group with the culture grown out in 
ascites broth, 24 hour growth, centrifuged, washed, and inoculated 
in normal salt solution. One hundred per cent of the rabbits de- 
veloped acute rheumatism, and 93 per cent acute heart involve- 
ments. The same organism was grown on artificial media for 
seventeen days, when another group of animals was inoculated, 
only 10 per cent of which developed heart lesions. All other con- 
ditions were as nearly constant as we could maintain them. 

On inquiry of men who have stated that they had succeeded in 
developing evidence of elective localizations, and of others who 
have similarly experimented, but have not developed localiza- 





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288 



CHAP XXII i.l 1a riVELCX u IZATION VNDORG wmh i-.im I Mi I 1 1 \ 289 

uons, we have found many instances where it seemed that the 
explanation might be found in the methods of procedure, includ- 
ing the Length of time the organisms had grown on artificial medi- 
um and the nature ot" that medium. For example, some men 
plate out the organisms on Petri dishes, pick off a colony in 24 or 
IS hours, plate it on another Petri dish and when it has grown 
sufficiently to plant others, transfer again until finally enough 
dishes are covered, from which to wash the organisms for inocula- 
tion. which may take several days. In some cases, with which we 
are familiar, the organisms were grown in artificial media for five 
days, and in other cases as long as seven days. This is so impor- 
tant a factor, that it might well be used as an experiment to de- 
termine whether or not growing the organisms on artificial media, 
would efficiently eliminate elective localization qualities, if they 
existed. 

In studying our large groups of inoculations, we find very dis- 
tinct evidence that some types of lesions produce very large per- 
centages of localizations whereas others do not. We have also 
found that different types of the same lesion will produce in some 
instances very large percentages of localizations, while others 
will produce a low percentage. In Figure 143 we show the result 
of inoculating 187 rabbits with cultures from the teeth of thirty 
different patients. This group represents a quite large variety 
of conditions, some acute, some chronic, some without lesions. 
The result of this study has shown that, in a large number of in- 
stances where the process was an acute one, the method of inocu- 
lation used showed evidence of elective localization in a high per- 
centage of cases, often 100 per cent ; that where the process was a 
subacute or chronic one, it was often a low percentage of localiza- 
tion ; and when there was no lesion, there was often a very indefi- 
nite expression in the rabbits or no expression. (See the last 
three.) 

There are many factors involved which modify the final results 
as, for example, the relation of the size of the dose to the weight of 
the animal. Many experiments are recorded in these various 
studies which illustrate this, though this mass action relation has 
not always been the purpose of the experiment. A splendid illus- 
tration of this phenomenon is shown in Figure 144 by inoculating 
three rabbits, Nos. 571, 572, and 573, with the same quantity of the 
same strain. All three were inoculated intravenously September 
13 with 1 cc. of culture from four incisors, grown out 24 
hrs. in plain broth; organisms washed and suspended in sodium 



290 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




Figure 144. Multiple kidney abscesses produced in three rabbits. All received the same 
culture and the same time factors. results are inversely with the weights of the rabbits. 

chloride solution; three billion to 1 cc. All were chloroformed 
September 19. Since all were posted after the same length of 
time the results are comparable. This culture had a marked 
affinity for kidney tissue, and the figure shows the three pairs of 
kidneys from these rabbits, mottled with multiple abscesses; the 
smallest rabbit almost completely covered with abscesses; the 
next larger, many less; and the largest rabbit, relatively only a 
few visible on the surfaces; yet the elective localization was clear 
in them all. 

This quality of elective localization is an exceedingly variable 
one. In some cases large percentages of the rabbits will have 
principally or exclusively one lesion, which may or may not be 
the lesion from which that individual is suffering at the time. 
This is illustrated in the chart in Figure No. 145 in an analysis of 
the lesions of the different rabbits inoculated with the cultures from 
a series of patients with involvements of joints and muscles. We 
could pick many dozens of cases, if we simply wished to present 
positive evidence, in which from 75 to 100 per cent of the rabbits 
had developed joint and muscle involvements. This group is se- 
lected to show that it is not always so. 

The first patient was suffering from an arthritis, acute and 
chronic. Four rabbits were inoculated. All developed acute 
rheumatism; but in addition, one developed heart, two liver, one 
gall-bladder, one intestines, two kidneys, and one had a brain 
lesion. 

The second patient suffered acutely from rheumatism. Nine 
rabbits were inoculated. Seven rabbits developed acute rheuma- 
tism ; one developed liver involvement, and two heart. A striking 
thing about this series was, that every rabbit was chloroformed 
after it had developed acute lameness, such as carrying its leg, 



CHAP. XXII ELECTIVE LOCALIZATION VNDORG ttl SUSCEPTIBILITY 

foin rs \m> mi scles 



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Case No. 

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182 


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22 





11 























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78 














100 










1065 


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X 


















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X* 










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257 


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260 


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X 




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X 




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X* 












262 


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X 


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X 




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67 

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100 


33 





67 





67 








33 


33 


100 














33 










1065 


































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416 


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423 


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184 


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3 Rabbits 


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33 





100 











































67 


2-18 


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X 


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199 


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X 


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1 Rabbits 




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30 


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20 








40 








20 


30 


50 














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68 


35 


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58 


12 


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25 


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66 








5 





67 



Figure 145. 



292 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

which process subsided; and at the time of the postmortem, in 
only two of these rabbits was there still evidence of the lesion 
which had expressed itself so acutely, usually about two days 
after inoculation. In the previous case of the four rabbits de- 
veloping acute rheumatism, only two showed involvement of the 
joints at the time of postmortem, and two involvements of the 
muscles. In the fourth one the involved tissue had apparently 
entirely recovered. 

The next two cases are the same patient at two different times. 
Her disturbance was recorded as myositis, neuritis, and lumbago. 
At the time of the inoculation of the first group of rabbits, all 
three developed acute rheumatism; but, in addition, two devel- 
oped heart, one lung, three liver, one gall-bladder, two intestines, 
and two kidney. Later, after her acute process had subsided, 
another group of rabbits was inoculated with the culture from 
another tooth, at which time none developed rheumatism, all 
three developed liver involvement, and that acutely; and with 
the exception of one rabbit which had a severe heart lesion, there 
were no other lesions in any of the three rabbits. Note that in 
both series of inoculations from this patient all of the rabbits 
developed lesions of the liver, which lesion appeared in only one 
rabbit out of nine in the preceding case. 

In the last case the patient suffered from acute rheumatism. 
Ten rabbits were inoculated. Five of the ten developed clinical 
rheumatism and one myositis, making six rabbits with joint and 
muscle involvement. Three had heart involvement, three lungs, 
three liver, two with stomach, and four with kidney involve- 
ments. These rabbits were inoculated with the culture from the 
teeth at the time the patient was having acute rheumatism and 
from which she had been suffering severely for some time. Inci- 
dentally, she has not had a recurrence of the disturbance since the 
removal of the infected teeth three years ago. 

In this case the first and sixth rabbit in the list were inoculated 
with washing from the teeth, followed by a culture from the teeth 
two weeks later. This will be discussed again under anaphylaxis. 
The effect of the previous injection with the filtered washing was 
to make these rabbits much more sensitive to the culture grown 
from those teeth. One of these rabbits died three hours following 
this injection, notwithstanding the fact that it was the first time 
organisms had been injected into this rabbit, and the dose was 
not large enough to produce serious or immediate disturbance. 
The other died on the second day. 



CHAP. XXII II EC riVE LOCALIZATION \\l> ORGAN SUSCEPTIBILITY 293 



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13 Rabbits 


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Fic;rRE 146. 



294 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

Few tissues have shown a higher percentage of localization 
than eyes when the process is an acute one. It does seem neces- 
sary, however, that the culture be taken from the tooth at a time 
when the patient's eye is in a state of acute reaction. This is il- 
lustrated in Figure 146 on Eyes, which shows three cases. 

In the first, thirteen rabbits were inoculated from the cultures 
of the teeth of a patient with two types of lesions of the eyes : ex- 
ophthalmos and extreme pain from the rupturing of blood vessels. 
This case is shown in Chapters 65 and 66. Of the thirteen 
rabbits 62 per cent showed eye involvement, 69 per cent showed 
intestines and digestive tract involvement, and many other 
severe lesions are recorded. 

In the next case, eleven rabbits were inoculated and all devel- 
oped acute eye involvements. This patient was almost totally 
blind in one eye and about four-fifths blind in the remaining eye. 
Note : With the exception of one rabbit which developed multi- 
ple lesions, most of the other rabbits developed only eye involve- 
ment. 

The next patient had acute recurring involvement of both 
eyes, as part of a blood stream infection complication. Of the 
twelve rabbits, seven or 58 per cent developed eye involvements; 
50 per cent developed rheumatism, from which the patient was 
suffering severely, and 58 per cent developed heart involvement, 
from which the patient also suffered. 

A group of inoculations selected from patients with acute di- 
gestive tract disturbance, shown in Figure 147, will illustrate the 
variableness of this quality of elective localization of the organism 
growing in the teeth, where the patient is suffering from acute or 
chronic processes. 

In the first case four rabbits were inoculated and all four de- 
veloped acute intestinal involvement. The patient suffered from 
a diarrhea with movements every fifteen minutes. All of these 
rabbits developed diarrhea with this strain. All four were acutely 
involved. 

In the next case the patient suffered from acute digestive tract 
disturbance. Of the six rabbits, three developed involvement of 
the stomach and intestines, one also of the gall-bladder and liver. 

An effort was made to extract a toxin by passing the cultures in 
their media through Berkefeld filters. The filtrate, bacteria-free, 
was inoculated, and produced in nine rabbits, or 44 per cent, in- 



CHAP. XXII ELECTIVE LOCALIZATION WD ORGAN m S( EPTIBILm 





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Case No. 

and 
Lesions 


1019 

Diarrhea. Lame- 
ness in right 
shoulder and 
arm. Lassitude 

1 Rabbits 

1098 

Digestive tract 
Lassitude 

6 Rabbits 


Stock Toxin 

9 Rabbits 

1057 

Digestive Tract 
Heart. Rheuma- 
tism 
Acidosis 

6 Rabbits 


> 

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296 DENTAL INFECTIONS. ORAL AND SYSTEMIC- RESEARCHES— VOL. I 

testinal disturbances, liver involvements in 67 per cent, heart 
33 per cent. This is discussed in detail in another chapter. 

In the last case the patient suffered from a very acute digestive 
tract disturbance. Six rabbits were inoculated. None developed 
lesions in either stomach or intestines, three developed lesions in 
heart, two in liver, two in gall-bladder, three myositis and clinical 
rheumatism. This patient's primary condition was an acidosis, 
of which he died subsequently, but which had been apparently 
overlooked in his previous symptomatic treatment. His digestive 
disturbance, like several of his other expressions, was entirely 
secondary. 

An analysis of one thousand rabbits, inoculated with cultures 
from dental sources of various patients, reveals some very interest- 
ing data in relation to the generative organs, as shown in Figure 
148. It is very striking that in this large number of rabbits, approxi- 
mately half of each sex, exceedingly few instances of involvement 
of the ovaries, tubes, and uterus of females, or testicles of males, 
have occurred where the patient from whom the culture was taken 
did not have acute infection or evidence of pathological condi- 
tion of the generative organs. 

The first and third cases in this chart are the same individual 
whcse case is described in Chapter 62. In the first group 
of six rabbits there were fcur females and two males. This 
patient was suffering from ovarian disturbance so acute that she 
was kept in bed nearly a week at the time of her periods and suf- 
fered exceedingly. She had been struck over her ovary in playing 
golf some years previously, since which time, she had always had 
severe distress at the time of periods. The four female rabbits 
all developed acute infection of the ovaries and tubes, as illus- 
trated in the chapter referred to above. The two males showed 
no involvement of the generative organs. At the time of her 
first involvement, some seriously involved teeth were extracted, 
and a root resection was made of a central incisor, with the hope 
that it might be saved or made safe until the end of her college 
year. Her trouble, which had been relieved by the removal of the 
dental infections on the first occasion, recurred. This question- 
able tooth which had been resected was removed ; the culture in- 
oculated into three female rabbits, two of which developed acute 
infection of the ovaries and tubes. Incidentally, she has not had 
a moment's return of her trouble since the removal of the last of 
these infected teeth. 



CHAP. XXII ELECTN E LOCALIZATION ttlDORGANSl S< 1 l'l IHII.I n 





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ease No. 

and 
Lesions 


1085 

Ovarian Pain 
Headache 
Backache 
Lassitude 

6 Rabbits 

1124 

Pelvic inflamma- 
tion and dis- 
charge. Neuritis 

Rheumatism 

Lassitude 

Headache 

7 Rabbits 


1 1 (85 

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Lassitude 
3 Rabbits 


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15 v 

« re 

2S_. 



298 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

When patients are suffering from endocarditis in its acute form, 
cultures from the infected teeth tend to reproduce heart involve- 
ments in animals in a very high percentage. This is illustrated in 
Figure 149 on hearts. In the first patient shown, five rabbits were 
inoculated, all developing acute heart involvement. In the 
second case, that of a child bedridden with acute endocarditis, 
three rabbits were inoculated with culture from a deciduous tooth. 
All three developed acute heart involvements. In the third case 
the patient was a woman between thirty and forty years of age 
with acute heart involvement and dyspnea. Six rabbits were in- 
oculated. All developed acute heart involvement. In the fourth 
and last case, the patient had been bedridden for many months 
from acute heart involvement. Two rabbits were inoculated. 
Both developed acute heart involvement. These sixteen rabbits 
inoculated with cultures from four patients with heart involve- 
ment all developed acute heart involvement. 

Other instances which illustrate the nature of the quality that 
organisms possess, of electing the same tissues that are involved 
in the patient, are shown in practically all the chapters from 59 
to 69 in which are discussed the systemic expressions of dental 
infections, and in many of which, illustrations are produced of 
involvements in the animals. 

We have in the preceding paragraphs of this chapter discussed 
the quality of the organism to elect a certain type of tissue. We 
wish now to discuss the quality of defense and susceptibility of 
the various organs and tissues of the body in relation to invading 
organisms. Few of our problems have been so difficult of approach 
as the study of the nature of these forces which decide what tis- 
sues will be selected, and why, in cases of dental and other focal 
infections. It is only recently recognized, that focal infections 
may express themselves in other and various tissues of the body. 
We will approach this subject first by a clinical analysis of the 
various cases presenting, to determine, if possible, whether there is 
any inherent force in the individual, or whether it is in the bac- 
terium. Problems 2 and 4, discussed in Chapters 2 and 4, in- 
clude a study of the nature of invading organisms and suscepti- 
bility. In these we found that an analysis of many hundreds of 
people suggests a classification into three fundamental groups: 
Those with absent susceptibility, those with acquired suscepti- 
bility, and those with an inherited susceptibility, with some ten- 
dency to combinations of these types. These also showed that in 



CHAP. XXII ELECTIVE LOCALIZATION tNDORG INSUSCEPTIBILITY 





Uliojoiom -) x x x » M M M MJg g 




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Case No. 

and 
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Arthritis 

5 Rabbits 

1058 
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Rheumatism 

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311 

Heart 

Rheumatism 

Neuritis 






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300 DENTAL INFECTIONS. ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

cases of acquired susceptibility, a large percentage of the lesions 
were in the nervous system; and in inherited susceptibility, there 
were both the presence of a lowered defense to streptococcal in- 
fection, and a distinct tendency to similar localization in different 
members of the same family to similar tissue and organ localiza- 
tion. 

It is a matter of very great importance whether defense is a 
purely general quality in which the tissue selected in elective lo- 
calization is purely accidental selection, or whether that tissue 
which breaks in a given individual has a predisposition, 
rather than a predilection on the part of the organism, for that 
tissue. To determine this, we have analyzed a large number of 
susceptibility records and case and family records. One of these 
studies is shown in Figure 150 under the title of "Organ Suscepti- 
bility" in which ten patients and their families are used in each 
group. We have taken ten typical patients each with rheuma- 
tism, heart involvements, nerve tissue involvements, and internal 
organ involvements. In the ten families in which the patients 
were suffering from rheumatism, we find that the total number of 
cases of rheumatism in all the ten families is 59. This includes 
the ten patients, their parents, the brothers and sisters of their 
parents, the patients' brothers and sisters, and the patients' 
grandparents, but not the patients' children, since the other parent 
would furnish half of the influence. The number of cases of heart 
involvement in all the members of these ten families combined is 
7, nerve involvements 19, internal organ involvements 19. 





ORGAN SUSCEPTIBILITY 










Ten Patients and Families in each Group 








Total No. of These Lesions in Family. 


No. of Patients Affected with Lesions 




Rheumatism 


Heart 


Nerves 


Internal 
Organs 


Rheumatism 


Heart 


Nerves 


Internal 
Organs 


Rheumatism 
Heart 
Nerves 
Internal Organs 


59 

24 
15 
13 


7 

57 

9 

9 


19 

25 

142 

30 


19 
13 
28 
90 


10 

6 
6 

4 


2 
10 

2 



4 

7 

10 

9 


4 

3 

7 

10 



Figure 150. 



In the next group, ten patients with heart involvement, the 
total number of cases of heart involvement in the ten families was 
57, of rheumatism 24, nerve tissues 25, internal organs 13. In 



CHAP \\ii ELE< riVELOt VLIZATION VNDORG w SI SCEP1 mill n 301 

the tt'ii patients with involvements of the nervous system, the 
total number of nerve lesions in the ten families was 142, rheuma- 
tism 15, heart 9, internal organs 28. In the ten patients with 
affections of the internal organs, the number of eases of serious 
involvement of internal organs in all the members of the ten 
families was 90, rheumatism 13, heart 9, nerves 30. 

The second part of this chart shows a similar study limited to 
the ten patients, not including the various members of their fami- 
lies. In the group of ten with rheumatism there were two cases of 
break in the heart, lour of the nervous system, and four of internal 
organs. In the group of ten patients with heart involvement six 
had rheumatism, seven nerve involvements, and three internal 
organ involvements. In the ten patients with nerve involve- 
ments, six had rheumatism, two heart involvements, seven inter- 
nal organ involvements. In the ten patients with internal organ 
involvements, four had rheumatism, none had heart involve- 
ments, and nine had nerve tissue involvements. It should be 
noted in passing (and I have discussed it in other chapters), the 
important relationship between involvements of the nervous 
system and internal organs. 

In Chapter 2, I have discussed the behavior of organisms and 
have found that they tend very strongly to acquire qualities in 
accordance with the culture medium; that they do not have 
physical expression or elective localization in accordance with 
their biologic classification as members of the streptococcus 
group. An analysis of the data in Figure 41 of Chapter 4 and also 
in Figures 42, 43, and 44 of the same chapter, reveals that with 
increased susceptibility, there is a marked increase in the number 
of breaks of the rheumatic group, but that these tend to appear 
limited to certain tissues in any given individual, but that these 
tissues differ widely in different susceptible individuals, but in ac- 
cordance with a common tendency within that family. The con- 
stantly heard reference to certain rheumatic lesions, such as that 
rheumatism and heart involvement prevail in certain families, 
is borne out in every phase of our study of the more exact rela- 
tionships in this matter of susceptibility. 

In Chapter 4, we recorded that in 681 individuals (being the 
cases selected from 1400 cases) studied with their families, those 
cases whose records were considered sufficiently complete to jus- 
tify comparisons and deductions, all others being rejected, there 
were 940 cases of heart ; and that over half of these appeared in 



302 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

PROGRESSIVE TISSUE AND OR 



Susceptibility 
Group 


bo 

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CD 

bo 
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u 

V 

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< 


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ra 

o 

6 

2 


w 

JD 
"ra 
E 

CD 

fa 

14-t 

o 

d 
2 

7 

9 

10 

12 

11 
14 


No. of Patients 
Having Lesions In: 


No. of Patients Having 
Relatives Affected 


to 

'co 
C 

4 
6 
8 

9 

7 

12 


E 

CO 

'•£ 

E 

3 

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2 

2 

7 
14 

13 

14 
11 


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6 

4 
12 


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2 

2 
8 
9 

11 

12 

14 


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CD 
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2 

2 
13 
12 

12 

15 

15 


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3 

ra 

u 

o 

"ra 

3 
u 

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+-> 
C 

1 

8 

7 

10 
10 
14 


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CD 

3 

CO 
CO 

P 

.Is 

CD 

a 

CO 

1 
8 
7 

11 

13 

13 


u 

OJ 

o 

ca 

4 
5 
9 

5 

12 


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u 
a> 

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1 
7 

11 

6 

11 


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J= 
ra 
fa 

4 
2 
9 

12 

10 

15 


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CO tu 

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55 
ra <ii 

1 
6 
7 
6 
15 


u 

cu 

1 

5 

2 

10 

14 

12 

15 


*j re 
2Di 


Absent 

Acquired 

Inherited 

1 side mild 
Inherited 

2 sides mild 
Inherited 

1 side strong 
Inherited 

2 sides strong 


40.7 
47.9 
43.4 

40.9 

39.4 

33.9 


8 
6 
5 

3 

4 
1 


3 

9 

11 

10 

14 



Figure 151. 

100 families, while over half of the families or groups contained 
no heart involvement. Figure 151 shows the progressive nature of 
this quality with the factor of intensity of heredity in a series of 
groups of individuals beginning with those without susceptibility 
or those with absent susceptibility, going through acquired sus- 
ceptibility, to those with strongly inherited susceptibility. From 
these data, we find strong evidence that the quality of suscepti- 
bility, when it obtains as a part of inheritance, tends strongly to 
be a factor of the organ rather than of the whole system, in which 
latter case, granting an inherited susceptibility to the rheumatic 
group lesions, it might be expected to attack organs and tissues 
entirely at random, in which case the percentage of incidence for 
given tissues and organs, while they might vary through a wide 
range in various families, would tend to average similarly in differ- 
ent groups. 

In Chapter 21, Influences which Modify Defensive Factors, 
we found that many forms of overload contributed to causing a 
break in a particular tissue. We can, accordingly, understand 
how a nervous system that is overloaded might tend to break; 
similarly, a heart that is exhausted. It is difficult on such a basis 
to account for the frequent occurrence of localization in a tissue 
of the animal corresponding with the tissue that was removed 
from the patient, but removed because of infection and disease. 
To illustrate : 

A case of an unmarried woman about fortv-six with marked 



CHAP. XXII ELECTIVE L0CA1 IZATION AND ORG ^NSl S< EP1 [BILITY 303 
G w [NVOl \ EMEN 1 OF GROUPS 





Total No of Lesions 






rotal No. 
"i 1 esions 


Average No. 

Ol Lesions 






No. "i Pati 


ents 






pei Group in: 










1 














in ( rioup 


per Family 






.ivitu; 






















•n 




•o 




























■3 




ra 




ppi 












E 












1 
<3 








u 

2 

c 






be 
5 




c 

i 


5 


4-1 

2 


u 



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2 


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> 

S 

Z 




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'Q 

u 

a 


<u 

> 

u 

en 


4) 



> 

aj 


u 

> 
C/5 


3 

> 

</5 


8 

■2 
U 

6 


o 
o 


c 
u 

a 

O 


■8 

u 
3 


S 


q 

it 
•a 
C 

5 


4 


7 


7 


7 


2 


16 


31 


1.07 


2.07 


6 


6 


9 


10 





6 


11 


l 


9 


37 


11 


15 


63 


96 


4.2 


(i I 


12 


5 


5 


13 


5 


3 


12 


15 


13 


18 


66 


28 


19 


l il 


201 


9.6 


L3 1 


10 


5 


6 


13 


5 


3 


21 


61 


29 


19 


92 


56 


30 


227 


308 


15.3 


20.53 


1 1 


3 


4 


12 


6 


5 


16 


51 


30 


27 


105 


78 


31 


258 


338 


17.2 


22.53 


12 


3 


3 


12 


4 


5 


47 


106 


77 


50 


254 


106 


114 


483 


754 


32.2 


50.27 


14 






13 


1 


10 



Figure 151— Continued. 



involvement of the cervical and dorsal plexuses (involvement of 
the neck and upper part of spine) was under study. It was de- 
cided that the teeth were involved. They were removed and 
cultured, and animals were inoculated, with the result that sev- 
eral female rabbits developed acute infective processes of the 
ovaries, tubes, and uterus. This patient had had first one ovary 
and tube removed, and later the other ovary, tube, and uterus 
removed because of acute involvement. 

In the chapter on Primary and Secondary Sex Organs, we dis- 
cuss a number of cases where the tissue affinity involves these 
organs, and make comparisons with the percentage of incidence 
of affection of these tissues where the patient was not affected, 
which latter is almost zero. 

This raises the important question as to whether that quality 
or property of the bacterium, which determines that it shall 
localize in some particular part of the animal into which it is in- 
jected (and which quality has in Chapter 2 been shown to be 
very transitory and easily lost) is derived from one of the three 
following factors: First, a condition obtaining in the focus, the 
tooth in this instance, tending to develop in the organism a qual- 
ity for selecting this type of tissue ; second, the fact that the organ 
is diseased furnishes to the organisms growing in the focus an ap- 
petite or affinity for that diseased tissue, through some substance 
passing to it through the culture medium, derived from the circu- 




I 





Figure 152. Spontaneous hemorrhages causing death in twelve hours. A. thigh: B. chest 

WALL; C, HEART MUSCLE; D, STOMACH LINING. 

304 



Ul\i' \\ii ELECTIVE LOCALIZATION AND ORGAN SUSCEPTIBILITY 305 




B 



t 



* 



~\ 



r> 




CI] 











FIGURE 153. Secoxd rabbit with SAME CULTURE AS FIGURE 152. A. OTHER THIGH OF Figure \'i'2. 
B AND C, ANOTHER RABBIT RECEIVING SAME CULTURE; B, HEMORRHAGE INTO KN'EE; C, BACK MUSCLES. 

lating blood and lymph; and third, whether normal defense pro- 
vides in the blood stream a series of defensive factors suited to 
each and all of the various tissues of the body, the absence of any 



306 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

one of which tends to develop in the blood stream a medium so 
affecting the organism growing in the focus, that it tends to select 
that tissue when transferred to a new host. This has suggested a 
series of studies to determine these factors. In other chapters I 
discuss the general systemic factors which seem to relate quite 
similarly to all types of localization. These three problems are so 
fundamental and the reseaiches that I have made upon them are 
so extensive that we will discuss them in the three chapters 
following. 

A striking illustration of the decrease in the elective localiza- 
tion quality of a strain is found in the following case history, 
which is written up in further detail in Chapter 60 (Circulation 
Disturbances). The patient had been suffering from myocarditis 
and stomach involvement. Within a few hours after the extrac- 
tion of his first two teeth, he had a secondary hemorrhage which 
was very profuse and difficult to control. In fact, he had been 
kept in the ward after the extraction, both because of the serious- 
ness of his illness and the slowness of the clot formation. 

The culture grown from his two extracted teeth, one 
an infected vital pulp, was inoculated into two rabbits. 
One of these rabbits (R. 1065) died in twelve hours from 
spontaneous hemorrhages throughout the body, shown in 
Figure 152-A, B, C, and D, and also 153-A. A shows 
the hip and thigh, with multiple hemorrhages; and when 
the thigh was cut across, or the muscle in any part of the 
body, these multiple hemorrhages were to be seen everywhere. 
B shows these multiple hemorrhages in the intercostal muscles; 
C a section of the heart muscle, with blood cells extra vasated 
between the muscle cells; and D, a hemorrhage into the mucosa 
of the lining of the stomach. The other rabbit (No. 1064) was 
chloroformed in twenty-four hours, and showed a similar, but less 
pronounced, condition. See Figure 153-C. Three other rabbits 
were inoculated with this culture on the following day. It will be 
noted that these showed very much less acute and violent reaction 
than those that were inoculated the previous day, probably due to 
a difference in the number of generations of organisms that had 
developed in the new environment, the first generation of organ- 
isms always being the most virulent and specific. One of these 
(R. 1069) was chloroformed in four days and showed subcuta- 
neous hemorrhages in the lumbar region and over the tibiae. This 
is shown in Figure 154, B and C. Another (R. 1068) showed 





Figure 154. Less severe lesions produced by later generations of same culture. 
A, hemorrhage from eye; B, back muscles; C, chest wall. 

307 



308 DENTAL INFECTIONS, ORAL AND SYSTEMIC—RESEARCHES VOL. I 

hemorrhages in the muscle tissue of the lumbar region in the back 
and also the ventral region in the psoas muscle, shown in 
Figure 153-B. The third (R. 1067) showed a periosteal hem- 
orrhage over the right eye, seen in Figure 154-A. Note that the 
patient's ailments had been diagnosed as involvements, primarily, 
of the heart and stomach with expressions in the nervous system. 
It is very probable that every culture medium influences to 
some extent, and in most cases very markedly and rapidly, the 
elective localization qualities of organisms that are transferred 
from the host to such artificial media and there multiplied. We 
would not expect a child, that was transferred from the camp of a 
savage man-eating tribe to the environment of a modern civiliza- 
tion, would, through its posterity for many generations, exhibit 
the flesh eating habits of the ancestors. Biologically, the cycle 
of growth, life, and degeneration, is very comparable in all forms 
of life, whether it be fourscore years for the man, twenty years 
for the horse, a dozen for the cow and dog, half that many for the 
fowl, a day for many moths, and perhaps hours for many of the 
microorganic forms. However, just as the egg is a resting stage 
in the life of the fowl, just so the bacterium may take on a condi- 
tion of suspended animation, or resting stage, in which it may or 
may net retain its aggressive qualities. In this substance with 
which we are concerned, the organisms apparently through their 
wonderful power of adaptation, quite rapidly change in the 
quality of elective localization and tissue affinity. 

SUMMARY AND CONCLUSIONS. 

We would summarize the first part of this chapter — namely, 
The Quality of Tissue Affinity or Elective Localization of Organ- 
isms — as follows: The organisms constituting the various strains 
of the streptococcus group are very different in their main char- 
acteristics from microorganisms that produce contagious and 
infectious diseases. These latter have, in the main, one principal 
type of expression. The organisms producing parotitis or mumps 
may also involve some other tissue as the testes, but in the main 
they tend to select parotid glands; and, similarly, Bacillus typho- 
sus produces typhoid fever with its characteristic involvements of 
Peyer's patches, enlargement of the spleen and mesenteric 
glands, and catarrhal inflammation of the intestinal mucous 
membrane; and, similarly, diphtheria, measles, small-pox, scarlet 
fever. Unlike these the organisms of this streptococcus group 
which, in general, find their way into the teeth to establish there 
a habitat, are often, if not generally, relatively harmless, non-viru- 






( HAP. XXII i:i EH riVELOC UJZATION AND ORGAN SUSCEPTIBILITY 339 

lenl strains. There is probably no one quality which makes this 
streptococcus so unique and characteristic, as its exceedingly 
great quality of adaptability to its environjnent. In Chapter 2 
we have discussed this quality of adaptability from another phase 
and have found that, regardless of the biologic classification, the 

organism tends to pick out certain tissues Of the' body in accord- 
ance with forces, other than those which establish the biologic dif- 
ferentiations. We also found that they could grow and learn to 
thrive in the presence of poisons, which originally were so toxic to 
them as completely to inhibit their growth in one-tenth of the con- 
centration on which they ultimately flourish. Our results of in- 
oculating these strains which have grown for periods of time in in- 
fected non-vital parts of the teeth, and sometimes in the vital 
structures, show these organisms to have taken on qualities of 
invasiveness which the free strains of the mouth do not obtain 
and which, doubtless, this organism did not have when it resided 
in the mouth. We have also found, as shown in Figures 143, 144, 
etc., that these organisms come to take on a quality, which is, inci- 
dentally, very transient and easily lost, of selecting not only a 
special tissue, when inoculated into rabbits, but very often the 
same tissue as that from which the patient was experiencing a 
severe lesion, as heart or kidney, eyes, etc. We also found that 
this quality of elective localization seems directly related to an 
acute process; that patients, for example, with acute heart in- 
volvements, acute rheumatism, iritis, or retinitis, are more likely 
to have the organism taken from dental infections, exhibit elec- 
tive localization qualities, than if the organism is taken from the 
teeth at a time when they do not have these acute processes. 

With regard to the quality of varying defense of a given organ 
or tissue in different individuals, our studies have seemed to in- 
dicate that all organs and tissues tend to have, normally, a high 
defense for streptococcal involvements; that various types of 
overload make these special tissues especially susceptible; and 
also that there seems evidence of the presence or absence of a 
specific element of defense for individual tissues independent of 
other tissues of the body, and which defensive quality tends to be 
similar in different individuals of the same family. In other 
words, there is strong evidence that the quality of organ and 
tissue susceptibility follows the laws of mendelian factors. We 
would, therefore, briefly summarize results of this research as 
follows : 



310 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

Dental infections may or may not contain organ- 
isms with a specific elective localization quality for 
certain tissues of the body. When they do so it is 
generally because the host is suffering, or has pre- 
viously suffered, from an acute process in that tis- 
sue, which acute process frequently, entirely and 
permanently, disappears with the removal of the 
focus of infection. There is evidence to indicate 
that the complete removal of an organ so affected 
does not destroy that elective localization quality 
in the microorganism of the focus. 

(Note: It should be noted that while I have discussed in the para- 
graphs of this chapter, the qualities of defense as expressed in organs 
and tissues, I do not imply, nor do I believe, that defense is limited to 
these structures. The researches on the nature and quality of the 
defensive forces in the circulating and other fluids of the body are 
discussed in other chapters). 



CHAPTER XXIII. 

THE ENVIRONMENT PROVIDED BY AN INFECTED 

PULPLESS TOOTH. 

PROBLEM: What are the characteristics of the habitat 
and environment furnished for bacteria in an infected pulp- 
it ss tooth? 

EXPERIMENTAL AND DISCUSSION. 

In studying this problem of the particular elements of environ- 
ment which an infected pulpless tooth furnishes, we will review 
first some of the characteristics of the tissues involved. The 
dental pulp and tubuli are filled with cellular and protoplasmic 
structures such as are included in highly vascularized special 
tissues. These are contained within bony walls in the form of an 
almost infinite variety of labyrinths producing such a maze, that 
if all the tubuli of a single rooted tooth were connected end to 
end, the total length would constitute three miles of enclosed 
channels. When we realize the inaccessibility of a large part of 
this network of intercommunicating channels and canals, we 
understand why it is so difficult to sterilize a piece of infected 
dentin even when it is immersed in disinfectants. A streptococ- 
cus tends to select necrotic and degenerating tissue elements. 
Mechanically, a putrescent tooth furnishes a highly ideal hiding 
place for this germ. It can adapt itself to almost any shape of 
physical environment in that it may grow so small as to pass 
through a Berkefeld filter of such fine mesh, that all microscopi- 
cally visible organisms will be taken out; and these minute or- 
ganisms which have succeeded in passing through the meshes of 
this filter, may, on reaching other media, grow to a size that is 
relatively large for organisms of the cocci group. 

Among Nature's most effective mechanisms of defense against 
this organism, are the phagocyting cells, chiefly the polymorpho- 
nuclear leucocytes. These cells have the wonderful property of 
being attracted to infective organisms, engulfing them, and neu- 
tralizing their toxic substance by the antitoxin within their own 
protoplasms. They may pass through cell walls into the inter- 
spaces by the wonderful mechanism of increased permeability of 

311 



312 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

the capillaries in a state of capillary dilatation as a part of the 
inflammatory process, and after engulfing the toxic substance 
may retreat from the field of inflammation and pass again into 
the circulating blood, or be carried away through the lymphatics, 
chiefly the latter, or in case of an exit, such as an abscess, pass out 
through the discharge. They are attracted to pathogenic or- 
ganisms by chemotropism, which is one of the marvels of the 
entire system of defense. They are completely baffled and help- 
less when it comes to the matter of entering an infected pulpless 
tooth to reach and destroy the organism producing the toxic sub- 
stances, or completely to eradicate the nidus because of the 
physical environment. 

It is difficult to conceive of a parallel where so complete a pro- 
tection is furnished to an invading enemy parasite entirely within 
the group of unit cells which, otherwise, would maintain a defense 
against it; for while the organism is entirely protected from the 
defensive mechanisms of the body, only one of which are the 
leucocytes, there is no other source of exit for their poisons and 
fluids of the host, except as an exit may be possible into the oral 
cavity through the rcot of the tooth. In dental practice we 
undertake to change completely this environment by annihilating 
the inhabitants of this part of the non-vital tooth structure, as- 
suming that the dentin is non-vital if the pulp is degenerated, and 
mechanically closing all entrance to this labyrinth and retaining 
it in a sweet and healthy condition as an inert, if not normally 
nourished, structure of the human body. 

There are several phases of this problem involved in this study, 
one of which is the nature of the boundary surrounding the den- 
tin of a tooth, particularly the dentino-cemental junction. There 
has been a great diversity of opinion as to whether or not there 
was direct communication between the dentin and cementum. 
(In another chapter I will discuss the matter of direct connection 
between the dentin and enamel). To determine this we have 
made a large number of histological sections, before speaking of 
which, however, we wish to refer to the excellent work of 
others, particularly that of Dr. Harold Box, 13 of Toronto. 
He seems to have demonstrated to his complete satisfaction 
the presence of communicating channels between the dentinal 
tubuli of the dentin and the canaliculi and the lacunae 
of the cementum. Marshall, on the other hand has furnished 

13. See bibliography. 



CHAP. XXIII ENVIRONMENT PRODUCED B\ INFECTED TEETH 313 

evidence which has seemed to demonstrate to him that the i 
mentum is laid down upon the dentin as an entirely independent 
structure, completely separated from it. Mummery, Hopewell- 
Smith, Williams, Boedecker, and many others, have discussed 
the relationship of the dentin to the surrounding structures with 
especial consideration of the problem of nourishment of tooth 
structure. Our own studies indicate that, in general, the cemental 
border ot" the dentin and the dentinal border of the cementum 
constitute what is apparently the same tissue, though in fact like 
a common fire-wall built by two different contractors, with oc- 
casional openings for communicating channels extending from 
one side to the other, which openings, however, constitute a rela- 
tively small part of the total area in this common wall, and which 
openings seem generally, if not nearly universally, to be special 
channels extending from the pulpal tissue to the peridental mem- 
brane, and which may have little, if any, communication by 
anastomosis, with either the dentinal tubuli of the dentin or 
with the lacunae and canaliculi of the cementum. They are, in 
effect, either very minute or larger multiple foramina. 

As one of several studies on this phase of the problem, I have 
placed metal tubes in the pulp chamber from the apex of the 
tooth, carefully cementing same, and have passed various fluids 
into the tooth under measured pressures. Several substances were 
tested, and it was found that both the sodium and the chlorine 
ions would pass from the pulp chamber of a freshly extracted 
tcoth through both the dentin and cementum, and the dentin 
and enamel, in easily measurable quantities. Among the easily 
passed ions was that of the calcium. 

When we study various tissues of the body, we find their func- 
tion is determined by certain inherent qualities pei taining char- 
acteristically to their cells. For example, whereas the various 
soluble products that are found in urine are entirely inhibited 
from passing through the tissue constituting the bladder wall, 
that same fluid will pass with great freedom and rapidity through 
the wall of the small intestine ; and similarly, the various glands 
and organs of the body have cells adapted to hold back certain 
substances and allow certain others to pass. In general, this 
problem is referred to as semipermeability, and it has to do with 
the function of every individual cell, as well as every type of cell, 
and is different in different tissues and cells. Electrolytes can 
pass through most membranes of the body ; colloids through but 



314 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

few of them. Hence the colloids of the blood stream cannot pass 
through the blood vessel walls, not even through the capillary 
walls, though the electrolytes can. When the colloids, which are 
largely proteins, are split into the various amino acids, they may 
pass through tissue cells in accordance with the structure of that 
molecule and the function of the cell in question. Each cell, 
therefore, may be thought of as a lock which takes a certain type 
of key. The various molecules of various compounds can be 
thought of as the key, and only those fitting the particular combi- 
nation in question, pass to that particular tissue. But electro- 
lytes and certain of the amino acid groups and their derivatives, 
will pass through tissues which are impervious to colloids and to 
bacteria. 

My studies of the dentino-cemental junction have led me to 
believe that certain substances can pass readily through this 
boundary, while the bacteria cannot. By placing organisms 
grown from infected teeth in sealed glass tubes, they very soon 
cease to multiply, and in a very short time nearly all are dead. 
Only a minute orifice is necessary to change quite completely the 
per cent of dead organisms. I have had sections cut from normal 
tooth structures, and have used these as semipermeable mem- 
branes to determine, if possible, whether or not food materials 
may pass through this structure while organisms may not, by 
connecting through glass tubes an infected and sterile culture 
medium, separated only by this partition of tooth structure, in- 
cluding the continuous wall of dentin and cementum cut from a 
suitable tooth. While these studies are not completed, the evi- 
dence available indicates that nutrient material can pass to the 
organisms through this structure, but that the organisms them- 
selves cannot pass. If this be true, the tooth in all probability 
furnishes a protection for the organism, in that neither the leu- 
cocytes nor the defensive bactericidal elements of the blood can 
reach the organisms within the dentin. The organisms in that 
position may receive a continuous supply of nutriment through 
the semipermeable, but to them impenetrable wall, making the 
boundary to the dentin. They are here completely protected to 
produce a toxic substance which may pass to the host and con- 
tinually irritate and injure the defensive forces of the host. If 
those defensive forces be sufficiently adequate to neutralize all 
toxic products immediately within the vicinity of the tooth, the 
warfare will be limited to that zone. This battle-ground and 



CHAP. Will ENVIRONMENT PRODUCED BY INFECTED TEETH 



315 



the battle are discussed in other chapters. If the products are not 
neutralized in the immediate vicinity of the tOOth, because of tin 

host's temporary or permanent inability to make that type of 
warfare, they may pass to the various organs and tissues of the 
body and irritate or sensitize them. The tooth, then, must be 
looked upon as an entirely different structure from flesh or living 
bone, since, if the pulp is dead, Nature has no mechanisms for 
disinfecting the dentin after it becomes infected, or of maintain- 
ing it if it is non-vital but sterile. She is compelled to make 
the warfare in the form of a quarantine about the tooth until 
such time as she can either absorb it or exfoliate it. A pulpless 
tooth is. therefore, a sequestrum; and if it becomes an infected 
sequestrum, must be dealt with as a foreign substance and not as 
a part of the host. 

An important question has been the matter of transfer of fluid 
from the dentin to the cementum or the enamel, or through both 
of these from the pulp to the fluids surrounding the different 
structures of the tooth. Bunting and Rickert" have demon- 
strated the passage of fluids from the inside to the outside of a 
tooth. 



.^ 



^ 



cr 



maxj 



Figure 155. Diagram of the apparatus which uses a section of tooth as a per- 
meable MEMBRANE. A, TOOTH SECTION; B AND C, CONTAINERS FOR SOLUTIONS BEING TESTED. 

Figure 155 shows the set-up of one of the experiments for deter- 
mining the permeability of tooth substance for nutrient products 
in culture medium on one side of a sac of the tooth structure, and 
living organisms in a normal salt solution on the other. The or- 
ganisms will not increase in number in normal salt solution to 
any very great extent. In the arm of the apparatus to the left, 
we have placed the sterile culture medium. If the organisms may 
pass through a sac of dentin and cementum, containing at least 

14 See bibliography. 



316 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

one, and in some instances two, dentino-cemental borders, they 
can go from the salt solution to the culture medium. By cultur- 
ing from time to time, as well as by its appearance, we can deter- 
mine the development of organisms on the medium side. If there 
chances to be a multiple foramen, and some teeth have as high 
as seventy-five, they may pass through these and not have to 
pass the true dentino-cemental boundary. If the infected normal 
salt solution remains clear and if its total bacterial count per 
cubic millimeter does not increase, we can assume that organisms 
have not developed more rapidly than they have died off. If, on 
the other hand, the culture medium is able to pass to the salt 
solution, either in whole or only some of its contained products, 
the organisms may multiply. We have run several kinds of con- 
trols. All of these set-ups were autoclaved. Some have normal 
salt on both sides, one infected and the other not ; some distilled 
water on one side and the other concentrated salt solution, to 
determine whether the tooth under these circumstances would 
act as a semipermeable membrane. Some contain electrolytes 
on one side and culture media on the other; others colloids. 

SUMMARY AND CONCLUSIONS. 

From the data here available it is suggested that the dentino- 
cemental border, under ordinary conditions, is an impenetrable 
barrier to bacteria ; that while the organisms cannot pass through 
it, toxic substances produced by the bacteria can, the extent of 
which is not yet completely determined ; that while the organisms 
cannot pass through this dentino-cemental boundary, nutrient 
substances from culture media surrounding the tooth can pass 
through this boundary. This boundary also forms a quite com- 
plete barrier against the defensive forces of the body, such as 
phagocyting leucocytes, bactericidins, etc. The tooth, therefore, 
furnishes an environment which is particularly favorable to the 
invading organism and unfavorable to the host, in that the for- 
mer is protected from the aggressive defensive forces 
of the latter, while able, by the natural laws governing 
the behavior of liquids and gases, to secure a continuous supply 
of nutriment through the walls of the fort. The placing of an 
infected tooth beneath the skin of the rabbit is many times more 
dangerous to the rabbit than the introduction of that bulk of 
concentrated infected culture ; and even though an infected tooth 
with apparently splendid root filling is thoroughly sterilized ex- 
ternally and placed beneath the skin of a rabbit, within a few 



CHAP Will ENVIRONMENT PRODUCED B^ INFECTED TEETH 317 

days it shows evidence, by changes in the hematology and chem- 
istry of the blood, of a progressive destructive change, which, in 
the majority of instances, terminates in death within two weeks. 
\\ e would, therefore, change our conception of the significance ol 
an infected tooth about as follows: from 

"(Old interpretation) Since the presence or absence 
and the extent of danger of infection in a suspected tooth, 
tire determined by the size of the pits sac at the end of the 
root, those teeth are dangerous which have this mass of 
infection external to the end of the root, and in proportion 
to its extent; ana 1 those are not dangerous which have 
little or no pus sac." to 

Since an infected tooth is a fortress for bacteria 
within the tissues of the host, and since, in accord- 
ance with the laws governing the behavior of sol- 
vents and solutes, the dissolved substances within 
the tooth can pass to the outside of it, and, simi- 
larly, the dissolved substances outside the tooth 
can pass to the inside of it, together with the fact 
that the defensive mechanisms of the body are quite 
unable to enter and reach the bacteria within the 
tooth except in exceedingly small numbers through 
the natural openings of the root, which openings 
will, however, permit the organisms to pass at will 
from within the tooth to the outside, we must con- 
clude that an infected tooth furnishes a condition 
and environment that is tremendously in favor of 
the invading organism inhabitating it, as compared 
with the host, since the latter may only rid itself of 
the menace by exfoliating it or absorbing it. 



CHAPTER XXIV. 

ELECTIVE LOCALIZATION AND ORGAN DEFENSE. 

PART ONE: INFLUENCE OF DISEASED TISSUE ON 

ORGANISMS IN THE DISTANT FOCUS. 

PROBLEM: Do diseased organs and tissues modify bac- 
teria growing in the distant focus, or create in them a capacity 
for elective localization for those diseased tissues? 

EXPERIMENTAL AND DISCUSSION. 

This is an exceedingly difficult but very important problem, for 
if it is true it not only removes from the organisms some of the 
culpability but furnishes an explanation for some of the phe- 
nomena which develop by transferring the organisms from that 
focus to another host. An analysis of our clinical records and 
experimental data throws some direct light upon this problem. 
In the second chapter preceding I reviewed a case in which the 
bacteria from the dental infection of a patient suffering from 
acute involvements in the cervical and dorsal regions, when in- 
oculated into experimental animals, developed acute involve- 
ments in the ovaries, tubes, and uterus, a lesion that is so rare, 
that not one per cent of experimental animals develops such a 
lesion from dental cultures of ordinary patients. Indeed, it had 
not been revealed in the taking of the physical history that this 
woman had had these operations, a secret which she carefully 
guarded. After the development of the lesions in rabbits, I asked 
her specifically regarding the history of disturbance in pelvic or- 
gans, when she gave me the history that one ovary and tube had 
been removed some years previously at one operation, and at a 
later time the other ovary, tube, and uterus. In this case, then, 
there were no such tissues to be involved. 

In Chapter 62 on "Primary and Secondary Sex Organs" we 
report a case with a very similar history. The woman presented 
with a heart involvement and rheumatism quite severe. The in- 
oculation of the rabbits developed acute involvements in the 
ovaries, tubes, and uterus, with an unusually severe involvemert 
of the uterus with extensive suppuration. I sent for the patient 
and asked her if she had given me the history correctly. She 

318 



CHAP Wi\ ELE( riVELCX \l l/Al [ON ^ND ORGAN DEF1 NSE 'M { J 

said she had not and thai she did not wish to think about it. let 
alone talk about it. since a purulent uterine discharge had been 
becoming more severe for six months and her physician had 
advised her that it was probably malignant and at her age an 

operation would not be justified. In this ease, as shown in that 
chapter, this purulent discharge completely subsided with the 
removal of her infected teeth and has not recurred in two years 
except for a couple of days at the time that an infected seques- 
trum was giving trouble after one of the extractions. Had the 
infected uterus been the primary lesion we would not expect 
that the removal of the dental infection would have seriously 
modified the primary focus, which is very important. 

In that same chapter we recite a case of a man from whose 
dental infection the cultures were taken and inoculated into rab- 
bits, and which produced acute infections in the testes of each of 
three male rabbits, the culture being taken from three different 
teeth. On being questioned, his reply was "Can't a person have 
any secrets?" and confessed that he had had a recent severe in- 
volvement of the testes; that he had had gonorrhea twenty years 
previously which had been treated and supposedly cured. 

In that chapter we refer to cases of ovarian cyst that have been 
operated and in which cases the cultures from dental infections 
developed ovarian cysts in the rabbits. 

It is not possible to state from these clinical cases to what ex- 
tent either the dental infection was originally causative in the in- 
volvement of these special tissues or to what extent these special 
tissues influenced the organisms growing in the focus. In the 
first case mentioned, however, it was seven years since the last 
operation; in other words, this individual did not have in her body 
primary sex organs to be related directly to the dental infection. 
It is true, however, that the dental infections which were removed 
had been of probably twenty years standing and her first opera- 
tion had occurred fifteen years previously. 

These data suggested some special studies which were con- 
ducted as follows: Tissues were taken from several different 
organs of the rabbit's body, macerated and placed in culture 
media inoculated with the same organism, a passive strain which, 
when it grew out, was inoculated into a series of rabbits, and 
careful macroscopic and microscopic studies were made to ascer- 
tain if the placing of healthy tissue of a given organ would tend 
to create in the bacteria an appetite for that tissue. These re- 



320 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

suits were all negative, which we interpreted as meaning that a 
normal healthy organ did not contribute elective localization 
qualities to organisms growing in a focus ; and that if such condi- 
tion does obtain — namely, that the infected organ develops the 
elective localization quality in a distant focus through the influ- 
ence of that organ on the culture medium — light might be gotten 
on this phase of the subject by the placing in the culture medium 
of some of the diseased organ tissue from an animal developing a 
severe lesion, as a result of inoculation of the animal. Since the 
organism which produces such a lesion does in many instances do 
so in several animals, it is evident that the organism had to that 
extent the power of elective localization. When, then, a diseased 
organ tissue is used for modifying a culture medium to determine 
whether or not that tissue will influence the organisms growing 
in that medium, that diseased tissue carries with it some of the 
original organisms having that quality. It is, therefore, im- 
portant to note that, when cultures are taken from diseased or- 
gans, which have become so because of elective localization quali- 
ties of bacteria, those cultures tend to produce lesions in that 
same tissue in the next animal passage, which quality we have 
assumed they were maintaining and not acquiring, having 
brought it from the original focus. We are, then, practically in 
the same position when we take a piece of diseased and infected 
organ to modify media, that we would be if we took the organ- 
isms without the tissue, in which we would expect elective locali- 
zation qualities. This, therefore, makes it impossible to deter- 
mine with this experiment whether an infected diseased organ, 
which disease was not produced by the dental focus, would so 
modify the organisms in a dental focus as to establish elective 
localization qualities. 

We have made many inoculations with organisms grown from 
the lesions which have developed in rabbits from dental infec- 
tions, and have seen many instances suggesting strongly that the 
organisms still had elective localization qualities. A first requisite 
for this experiment is to develop an acute or chronic lesion by any 
process in an internal organ; and, after it is well established, to 
establish a dental condition which would tend to become infected 
from the blood stream. To accomplish this I have undertaken 
the following experiment : 

Since we frequently find teeth, as illustrated in Chapter 63 on 
"Kidneys and Related Excretory Organs" which, when removed 



CHAP. XXI\ ELECTIVE LOCALIZATION WD ORGAN DEFENSE 321 

from the mouth of a patient having acute nephritis and placed 

under the skins of rabbits, product' acute kidney involvement 
which can be definitely identified by the presence of albumin and 
casts, and later verified by macroscopic and microscopic study, 
as shown in that chapter, we must consider the matter an open 
question until further data are available, the experiments for which 
are in progress. 

I wish to insert a warning at this point: Judging from the ob- 
servation as to the conclusions that are liable to be made by per- 
sons who undertake to check an experiment of this kind, I shall 
anticipate that some persons will undertake to put teeth under 
the skins of rabbits to determine whether or not it is possible by 
this process to accomplish this result. They may have negative 
results which, I shall anticipate, they will conclude are a proof 
that there was an error in my experiments. My warning is two- 
fold: Firstly, that just as all individuals that have infected 
teeth, do not develop kidney involvement, just so all rabbits that 
have inoculations made by any form do not always develop le- 
sions; and, secondly, all cases of nephritis are not caused by den- 
tal infection, and the tooth may be selected either from such a 
patient, or it may be a tooth with an acute apical involvement, 
and the kidney lesion a chronic one, in which case it will usually 
be true that the dental infection will not show marked elective 
localization qualities. 

There is another source of information, however, which is very 
important in answering this problem. The studies reported in 
the various preceding chapters, particularly Chapter 4, had to 
do with the particular tissue that tends to break in individuals 
with an inherited susceptibility, in which case they tend to break 
in the same tissues as did their ancestors and as do their brothers 
and sisters. It is abundantly demonstrated that this quality is 
transferred from generation to generation entirely regardless of 
its acute development in any particular link in the chain, in which 
case, if the individual was a carrier only of the quality without, 
having had that lesion develop or a lesion in that organ develop, 
it could not be said that a diseased organ had had anything to do 
with the quality of elective localization, since that was neither 
evidence of organ involvement nor of focal infection. It becomes 
clear, then, that this quality is something inherent within the in- 
dividual, which is transferred from generation to generation, 
which may skip, in accordance with the mendelian laws, individ- 
uals who themselves may be carriers of the quality. 



322 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

PART II. NATURE OF THE DEFENSIVE MECHANISMS. 

This brings us to the second phase of this problem: namely, 
whether normal defense provides in the blood stream a series of 
defensive factors suited to each and all of the various tissues of 
the body, the absence of any one of which tends to develop in the 
blood stream a medium so affecting the organism growing in the 
focus, that it tends to select that tissue when transferred to a new 
host. 

This is a very difficult but very important problem, since a 
knowledge of these factors is essential for an explanation of the 
phenomena that develop in clinical practice in the study of the 
various types of reaction, and of complete absence to reaction 
from dental infections. In this statement of the problem we have 
a distinctly different situation from that in the preceding para- 
graphs of this chapter in which we discuss the ability of a dis- 
eased organ to produce in the bacterium an appetite and quality 
of localization for that diseased organ, when the organism is 
transferred to a healthy host. In this part of the chapter we are 
not dealing with the presence of a definite substance which is the 
product of a diseased organ, but with the absence of some sub- 
stance which, if present, would constitute defense, but whose 
absence constitutes susceptibility. 

A line of approach to this question is suggested by the experi- 
ence of the eskimos in northern latitudes. It is said, for example, 
that in some of the North Sea Islands every eskimo, who became 
exposed to measles, died. We cannot say, however, that this 
was so because there was generated in his body some specific sub- 
stance which made him susceptible, for history shows, that for 
centuries on these same islands, no eskimo died of measles be- 
cause none were exposed to it. It is apparent that his absence of 
a defense, which the white races have in part built up through a 
process of infection in each generation and therefore of a trans- 
mitted immunity, is entirely due to a lack in his constitution of 
some qualities which, if present, would constitute defense, but 
which defense he did not require in the absence of being exposed 
to the contagion; in other words, the absence of a positive factor 
rather than the presence of a positive factor. 

When we study, then, our carefully worked out clinical histories 
in their relation to presence and absence of defense, as we have 
done in Chapter 4, and their relation to the particular types of 



CHAP.XXfV ELECTIVE LOCALIZATION \M » I >RG w DEF1 NSE 323 
CHARACTERISTICS OF Ac 1 1\ E AND DEFICIEN r IMMI MTV 



Suscept: 
Group 


., tcr- 

istics of 

/><■•. . 


Susceptibility 

to Sy.it cm ti 

I nvulvements 

from Dent.il 

Infections 


Carta 


Ptriodonto 

c /us 1.1 


n. i 

Call mm 


Absent 
Suscepti- 
bility 

Acquired 
Suscepti- 
bility 


Marked 

rarefying 

osteitis 

R irefying 
osteitis 
surrounded 

by condens- 
ing osteitis 

Mild or 
slight 
rarefying 
osteitis 


None 


Slight 


Marked 
tendency 
to 


Ionic 
calcium 
high 


Generally 
absent but 
recent acute 
attack 


Recent 

acute 


Previously 
a tendency ; 
is latterly 
not extend- 
ing 


Generally 

high. 

recently 

lowered 


Mildy 
Inherited 
Suscepti- 
bility 

Strongly 
Inherited 
Suscepti- 
bility 


Recurring 
attacks 

Frequent 
and severe 
attacks 


Recurring 
through 
life 


Very 

slight 


Generally 
lowered 


Slight 
rarefying 

osteitis 
with 
marked 
tendency 
to condens- 
ing osteitis 


Chronically 
severe 


Practically 
almost 
absent 


Chronically 
low 



Figure 156. 

expression which the same infection tends to produce locally 
about the infected teeth in these different groups, and compare 
these with the blood chemical analyses, saliva analyses, etc., of 
the individuals of these groups, we find that we are dealing in the 
main with individuals having very definitely differentiating quali- 
ties, already reviewed in Chapter 4. We find evidence that this 
quality of complete defense, or, at least ample to defend the in- 
dividual against systemic involvement for the major part of a 
lifetime from even several dental infections, has many identifying 
characteristics. If we group these various differentiating quali- 
ties for the different groups of individuals according to our classi- 
fication, we find a condition as shown in Figure 156. There are 
many other important factors which are variable in these various 
groups, one of which, and perhaps the most important of all, vari- 
ations in the defensive mechanisms of the blood in these various 
groups, is discussed in Chapter 41. 



324 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 
SUMMARY AND CONCLUSIONS. 

We are led to conclude from the available data, 
that we do not as yet have sufficient information 
to draw a close distinction between the influences 
of the organisms on the affected organ, in contra- 
distinction to the influences of the diseased organ 
upon the organisms in the focus. The available 
data suggest strongly, if they do not definitely 
indicate, that both these conditions exist, in some 
instances, either one acting entirely alone, and in 
some others there are indications that both exist 
at the same time. These data have suggested very 
definite researches that are being organized to 
throw further light upon this subject. 



CIIAITKR XXV. 

THE RELATION OF THE TYPE OF REACTION TO THE 

NA'ITRK OF THE IRRITANT. BACTERIAL OR TOXIC. 

PROBLEM: Have we different products from denial in- 
fo ction? 

i:\PKRIMENTAL AND DISCUSSION. 

In Chapter 17. we have discussed the presence of non-bacterial 
poisons of dental origin; and in Chapter 24, we have discussed 
the quality of bacterial invasion and its elective localization. 
This research was undertaken to determine what, if any, rela- 
tionship there is between the type of systemic disturbance and 
the nature of the irritant. One method of procedure has been to 
take from the teeth of patients suffering definite and acute sys- 
temic involvements, both the organisms growing therein, and the 
soluble poisons present in those teeth, and injecting these into 
experimental animals. In Chapter 18 under the discussion of 
"Studies of Pulpless Teeth," I presented a chart showing the 
effects on animals of injections with the washings from crushed in- 
fected teeth, both with and without filtering, and have compared 
these with the effects on animals of cultures grown from teeth 
(Figure 24, Chapter 2), either the same or similar ones, both 
when in media in which they were grown, and when removed from 
media and washed with several changes of normal salt solution 
and then inoculated in a normal salt solution suspension. By 
referring to those charts, it will be seen that the average length of 
life of animals injected with the washings of the teeth, was less 
in this group than in the groups inoculated with the washings 
plus the organisms, and also less than when injected with the 
culture of the organisms without the toxic substance from the 
tooth, whether the organisms were washed or injected in the medi- 
um in which they have grown. These figures were as follows: 

The average length of life of 13 animals inoculated with filtered 
washings from teeth, was 5 days; as compared with the group with 
unfiltered washings in which 8 animals died with an average life 
of 12 days. In the third group of 8 animals, inoculated with the 
organisms washed and suspended in sodium chloride, the average 

325 



326 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

length of life was 7 days; and in fourth group of 71 animals, in 
two series, 16 in the first and 55 in the second, receiving whole cul- 
ture, ( these organisms in the medium in which they grew, approxi- 
mately 1 cc. doses), in the first series of 16, the average length of 
life was 6 days, and in the second group of 55 was 7 days. In an- 
other chapter I have suggested an explanation for the phenome- 
non of the toxic substance killing in less time than the toxic sub- 
stance plus the organisms producing it. 

In our various efforts to study in a comparative way the injuri- 
ous effects of toxins and bacterial invasions, the comparisons have 
been more largely between miscellaneously selected toxins and 
miscellaneously selected dental cultures. I have, accordingly, 
undertaken to check this more closely by extracting the toxin from 
given teeth for inoculation as washings from the tooth in one 
group of animals, in some cases filtered, others not filtered, and 
comparing these effects with homologous cultures by growing 
the organisms from the particular tooth from which the toxic 
substance had been washed. A group of these is shown in Figure 
157. In the group showing changes in weight of rabbits inoculated 
with tooth washings, seven — namely, the sixth, seventh, eighth, 
tenth, eleventh, twelvth, and thirteenth, — were filtered washings, 
and the others of that group — namely, the first, second, third, 
fourth, fifth, and ninth, — from unfiltered. In this group the 
average loss in weight per rabbit was 131 grams and the average 
percentage loss 11>^. In the group inoculated with the culture 
from these same teeth, the average loss of weight per rabbit was 
180 grams and the average percentage loss 17. It will be noted 
that in this series the loss in weight was more rapid where they 
received the whole culture, that is 1 cc. of organisms and culture 
medium from a twenty-four hour growth, than where they re- 
ceived washings from the single tooth only. The difference, how- 
ever, was one of degree, for the effects were very serious with 
both. This suggests that when a patient is receiving the toxic 
material into the system in addition to the bacterial invasion, the 
injury would be distinctly worse than to receive either one alone. 
It is of interest to note that in this group of nine rabbits inoculated 
with washings, the rabbit that lost the greatest amount, both in 
total grams and in percentage — namely, number eight — received 
a filtered washing. This corresponds with some of the data shown 
in other studies which demonstrates that the toxic material in 
some teeth is extremely injurious, for the length of time required 



CHAP \W KM l \ l [I >\ I IF [RR1 I \\ l K ) [TPE OF RE M HON 





COMPARISON I 'i 


OOTH 


roxiN \M> 


[DOTH CUL 


H RE 










A 1 


(H)ih Washings 






Case 


Rabbit 


I ooth 
\\ ashing 
l Fnheated 


No oi 
Days 


\\ eight Changes 


( ,.im 


1 .< >ss 


' , (i llll 


\ Loss 


No. 


No. 


Fil- 
tered 


Unfil- 
tered 


Lived 
















Actual 


• 


ActU il 


% 


per <ii\ 


pei daj 


133 


145 




H 


11 






11 


3 9 




0.4 


89] 


274 




•' 


10 






101 


18 (i 




1 8 


101 1 






" 


6 






170 


10 1 




3 2 


1014 


294 




•• 


9 









0.0 




(. 


1081 






'■ 


11 






90 


9.4 




(i '» 


11 10 


592 


" 




1 






15 


1 3 




1 3 


1149 


593 


•• 




14* 






11 


1.0 




1 


11. .7 


542 


•• 




1 






278 


24.0 




6.0 


1153 


545 




'• 


34* 


124 


in 1 






0.3 




1171 


607 


•• 




11 






510 


34.5 




3 1 


1123 


521 


•• 




6 






191 


25 




4.2 


1177 


640 


•• 




7 






263 


21.0 




3.0 


1412 


753 












59 


4.9 




0.1 











B. 1 


'ooth Culture* 










Case 

No. 




Culture 


No. of 
Days 
Lived 




Weight Changes 


% Loss 
per day 




N iCl 
Sus- 
pen- 


( lain 


Loss 


% Gain 
per day 


Rabbit 
No. 


Whole 


Actual 


% 


Actual 


% 








sion 
















433 


146 


.. 




10 






309 


27.1 




2.7 


891 


275 


" 




32* 






334 


25.9 




0.8 


1014 


289 


•• 




5 






166 


18.6 




3.7 


1014 


293 




" 


22 






227 


30.6 




1.4 


1014 


294 




" 


9 






163 


20.5 




2.3 


1081 


291 




•■ 


43 


10 


13 






0.1 




1149 


591 




" 


11* 






118 


13.6 




1.2 


1149 


595 




•• 


13* 






13 


1.0 




0.1 


1149 


596 




" 


10 






535 


39.6 




3.9 


1149 


597 




•• 


11* 






105 


11.1 




1.0 


1157 


511 




" 


12 






144 


16.5 




1.4 


1153 


549 




" 


9 






230 


24.5 




2.7 


1153 


550 




" 


7 






318 


27.5 




3.9 


1171 


606 




" 


14 






174 


18.5 




1.3 


1123 


613 




" 


21* 






73 


6.0 




0.3 


1177 


643 




•• 


17* 


154 


14.5 






0.9 




1412 


755 
756 




•• 


9 
3 






329 
137 


31.0 
13.5 




3.4 

4.5 



Chloroformed 



Figure 1o7. 



for this rabbit to lose 24 per cent in weight was only four days. 
The average percentage loss per rabbit per day for the group 
receiving the washings was 1.8 and for the group receiving the 
inoculations of the cultures of the same teeth was 1.9 Another 
rabbit of this series, No. 592, receiving the filtered washings of a 
tooth, died in one day. On this account, it will be seen it is not 
sufficient to judge total loss, since a rabbit may be killed so quickly 
by the toxic substance of a filtered washing that it does not have 
time to lose in weight. 



328 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 
SUMMARY AND CONCLUSIONS. 

The evidence available indicates that infected 
teeth elaborate two distinctly different products, 
one being bacteria, and the other a toxic substance 
or group of toxic substances, which, independently 
of the organisms developing them, may produce 
various and profound disturbances in tissues in 
various parts of the body, one of the important 
group of disturbances being that of the blood 
stream. 



CHAPTER XXVI. 

( HEMOTAXIS AS A MEANS FOR INCREASING 

DEFENSE. 

PROBLEM: Can defense for streptococcal infections In 

increased by introducing enterally or parentertilly {by in- 
gesting or injecting) chemicals? 

EXPERIMENTAL AND DISCUSSION 

For hundreds of years the natives of Peru have been fighting 
malaria by chewing the bark of various species of cinchona trees 
containing the active principle of quinine. Modern science has 
perfected the process, and now injects into the circulation of the 
affected person, derivatives of that original compound, which are 
conceived of as having specific action on the Plasmodium which 
produces malaria. This might be looked upon as true chemo- 
taxis. Similarly, Ehrlick developed the administration of com- 
pounds of arsenic, known as "606" or salvarsan, which, under 
certain conditions, tends to be specific for treponema pallidum. 
Still later, compounds have been made of chaulmugra oil, which 
have very specific action in the treatment of leprosy. Similarly, 
Wright and others have used ethylhydrocupreinhydrochlorate 
in the treatment of pneumonia, particularly in epidemic form, 
which is disastrous in the mining districts of South Africa. 

With a view to determining whether or not some such products 
enhance the defense of rabbits inoculated with cultures of dental 
origin, we have made several studies in order to determine more 
exactly the effect of the medication. We have studied the mor- 
phology of the blood before and after its use. The chart in Fig- 
ure No. 158 shows the result of a series of inoculations made with 
ethylhydrocupreinhydrochlorate. The procedure of the experi- 
ment was as follows: 

The rabbits of a group of eight were inoculated with decreasing 
doses of a culture which was grown from a tooth of a patient 
suffering from an acute eye involvement. This culture was 
selected because of its uniformly fatal termination with dilutions 
from one cubic centimeter to one-eighth of a cubic centimeter of 
culture. The rabbits of this group are shown in Section I of the 

329 



330 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

CHEMICAL MEANS FOR INCREASING DEFENSE. 
Case No. 1131 



R. 
No. 


Chemical 


Amount 

of 
Culture 

cc. 


Method of 
Inoculation 


Days 
Lived 


Death 


Amount 
cc. 


Dilution 


Sponta- 
neous 


Chloro- 
form 



Section I. Eight Control Rabbits. 



458 






1.0 


Intra-V 


Vi 


* 




461 






1.0 


Intra-V 




* 




444 






1.0 


Intra-V 




* 




447 






1.0 


Intra-V 




* 




457 






1.0 


Intra-V 




* 




465 






0.5 


Intra-V 




* 




468 






0.25 


Intra-V 


V* 


* 




469 






0.125 


Intra-V 


3 


* 





Section II. Rabbits Injected with Ethylhydrocupreinhydrochlorate before Culture. 



407 


1/10 


1% 


1.0 


Sub-C 
Intra-V 


10 


* 




427 


1/10 


1:5000 




Sub-C 


10 




* 


*428 


1/10 
1/10 
1/10 
1/10 


1:1000 
1:100 
1:1000 
1:5000 


1.0 


Sub-C 

Sub-C 
Sub-C 
Sub-C 
Intra-P 


98 




* 


481 


1 


1:100 


0.25 


' Intra-V 
Intra-V 


30 


* 




484 


2 


1 °7 


0.5 


Intra-V 

Intra-V 


67 




* 


485 


1 


1% 


0.5 


Intra-P 
Intra-V 


14 


* 




486 


2.5 


v: c 


0.5 


Intra-V 

Intra-V 


78 




* 



Section III. Rabbits Injected with Ethylhydrocupreinhydrochlorate after Culture. 



482 


1.0 


1% 


1.0 


Intra-V 

Intra-V 


1 


* 




487 


3.0 


1% 


0.5 


Intra-V 
Intra-V 


1 


* 




512 


1.5 


1% 


0.5 


Intra-V 

Intra-V 


1 


* 





Section IV. Rabbits Injected with Culture and Ethylhydrocupreinhydrochlorate 

Simultaneously. 



490 


3.0 


1% 


0.5 


Intra-V 


23 


* 




510 


2.5 
1.0 
1.0 


1% 

195 

i<;, 


1.0 


Intra-V 
Intra-V 

Intra-V 


15 + 







* Rabbit 428 received both chemicals. 

Figure 158. 



CHAP. XXV] CHEMOTAXISASAMEANS FOP INCREASING DEFENSE 33] 

CHEMICAL MEANS FOR INCREASING DEFENSE 
Case No. 1131 



Chemical Amount 

K ~~ ~ oi Method of 

\ Vmount Dilution Culture Inoculation 

lV - cc 



Death 
Days 

Lived \ Sponta t hloro 
neou9 form 



s 


ection \ . 


Rabbits Inj 


vied with 


Ethj Ihydrocupi 


■einhydroch 


orate Al< 


IU'. 


521 


l (i 


] 




Inli.i \ 


29 








1 

1 

1 5 


1 1 
1 i 

P, 

1', 




Intra \ 
Intra \ 
Intra \ 


54 







Section VI. Rabbits Injected with Chaulmugra Oil Compound before Culture 



188 


2 


.) 


Intra-P 


70 


192 


1.0 




0.5 


Intra-P 
Intra-V 


45 


* 




"- 


i 




1 


Intra-P 


79 




* 



Section VII. Rabbits Injected with Chaulmugra Oil Compound Alone. 



477 


2 in. 






Sub-C 


28 


* 




480 


1 m. 
1 m. 






Sub-C 
Sub-C 


54 




* 


250 


1 cc. 

2 cc. 






Intra-P 
Intra-P 


36 




* 



* Rabbit 428 received both chemicals. 

Figure 158 continued. 

chart, in which it will be seen that all of the rabbits died in from 
twelve hours to three days, all but one in one day or less. The rab- 
bits which did not die during the work hours of the day on which 
they were inoculated, but were dead on the following day, were 
recorded as having lived one day. It is probable that several of 
them that are recorded as having lived one day, really lived much 
less than a day. The average, therefore, for the group would 
probably be pretty close to one day, which was too short a time 
for changes to take place that could be recorded as percentage loss 
in weight per day. 

Section II shows a group of seven rabbits that were inoculated 
with the indicated quantities of ethylhydrocupreinhydrochlorate 
prior to their receiving the indicated quantities of the same cul- 
ture as the rabbits in Section I, and it will be seen that most of 
these rabbits were still living in from one to two months, when 
they were chloroformed for tissue sectioning and study; and, 
whereas, one-eighth of a cubic centimeter of this culture sufficed 



332 DENTAL INFECTIONS. ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

to kill without the assisting protection of ethylhydrocuprein- 
hydrochlorate, those receiving it were enabled to withstand eight 
times that lethal dose for weeks or months. 

In Section III we have a group of three rabbits that were in- 
jected with ethylhydrocupreinhydrochlorate after, instead of 
before, receiving the injection with the culture, and it will be 
seen that these rabbits all died spontaneously within a day. In 
other words, the administration of this chemical after the inocu- 
lation had had an opportunity to establish itself, failed to rein- 
force the defenses of the body sufficiently to stamp it out or to 
protect the animal from its ravages. 

In Section IV we have two rabbits that were inoculated with 
the culture and ethylhydrocupreinhydrochlorate simultaneously, 
the first one of which lived twenty-three days, and the other 
was still in good condition in two weeks. 

In Section V we have two rabbits that received ethylhydro- 
cupreinhydrochlorate alone, and one of these was chloroformed 
in twenty-nine days and the other in fifty-four days, to ascertain 
the effect, if any, of the chemicals. 

Section VI shows three rabbits that were injected with chaul- 
mugra compounds before the culture, and it will be seen that the 
first one was chloroformed in seventy days, another died in forty- 
five days, another was chloroformed in seventy-nine days. 

Section VII shows three rabbits that received the chaulmugra 
compounds alone without the culture. The first rabbit died 
spontaneously in twenty-eight days, the second was chloroformed 
in fifty-four days, and the third was chloroformed in thirty-six 
days. 

From these data it will be apparent that these chemicals have 
shown evidence of reinforcing the defense of the rabbits against 
this culture which was taken from the infected tooth. The tooth 
itself was not giving the patient any trouble but was removed 
because of the fear of its having contributed to an optic neuritis 
which had completely destroyed the sight of this patient's eye. 
This culture, as previously stated, was used for this test because 
of its high virulence. There was, however, an unfortunate phase 
of the selection of this particular culture, which was that since 
there would be some reason to fear that it would have an affinity 
for eye tissues, since that was the serious lesion from which the 
patient had suffered, we might confuse elective localization 
qualities on the part of the organisms with elective localization 



CHAP XXVI CHEMOTAXISAS I MEANS FOR IN( REASING DEFENSE 

qualities of the defensive chemical injected. It so happens that 

one of these drugs namely, ethylhydrocupreinhydrochloratr 
has been suspected <>i producing injurious effects on the eyes of 
patients that were injected with it as a means of increasing their 
defense against the pneumococcus in cases of severe pneumonia. 
There is. however, a strongly expressed difference of opinion as 
to whether such injurious effects had been produced by this drug, 
or whether they were incidental or of other cause. In our rabbits 
inoculated with this culture, which was suspected to have had an 
elective localization for eye tissue, there was no opportunity for 
eye involvement to develop, since the animals were practically 
all dead inside of a day, only one living beyond that period, and 
it received an exceedingly small dose. Before this drug is used 
on humans as a means of reinforcing their defense against strepto- 
coccal infections, it is exceedingly important that extended re- 
searches be conducted to establish whether or not there is a 
danger of producing injuries to the eyes from its use. Several of 
the rabbits that received this drug prior to their injection with 
the culture, and which rabbits apparently had their lives length- 
ened or saved by the use of this chemical, developed conjunctiv- 
itis, and it was impossible to decide whether the lesion had been 
produced by the chemical or by the culture. Since, however, 
none of the controls which received the chemical without the 
culture, developed eye involvement, though they lived for from 
twenty-nine to fifty-four days before being chloroformed, it 
seems probable that the eye lesions which did develop, were the 
result of elective localization qualities on the part of the organism 
rather than the specific effect of this chemical. 

With regard to the chaulmugra compounds, I found great 
difficulty in securing suitable extracts or compounds, and I found 
it necessary to engage the services of a skilled pharmacologist to 
make for me special preparations for my studies. A number of 
preliminary studies were made by using the chaulmugra oil and 
resorcin or camphor, but a special sodium chaulmugrate proved 
to be the least irritating and most efficient. A group of rabbits, 
not shown in our charts, received various dosages to determine 
the quantity that would be lethal and the quantity that would be 
most efficacious. This is presented as a preliminary report and 
more extended and detailed information will be reported later. 

It will be noted that, of this group, many of the rabbits with- 



334 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




Figure 159. Proliferative arthritis shown in shoulders in B. A, 
normal; B, had received lethal doses of dental infection but had 
apparently survived because of the raising of its defense by 
chemotaxis. 

stood the lethal doses and lived on for long periods, and were used 
finally to see whether the use of chaulmugra oil continued to give 
them defense. Rabbit No. 664 had the following history: The 
rabbit received four injections on four successive days with a 
culture, one of which injections was expected to be sufficient to 
kill an ordinary rabbit. It had been prepared by a previous in- 
oculation with sodium chaulmugrate. It gained splendidly in 
weight and looked like a very normal rabbit. Its fur was sleek; 
and when posted, it was very fat, notwithstanding all of which, 
multiple arthritis was found, as shown in the roentgenograms in 
Figure 159. The roentgenograms of the shoulder joints of a normal 
rabbit are shown for comparison in the same figure in A. This 
would seem to suggest that, notwithstanding this animal was not 
able to prevent the localization of the organisms having an 



CHAP. \w l CHEMOTAXIS AS \ Ml VNSPOR INi RE ISING DEFENSE :::;.> 

affinity for joints, it was able in large measure toresist the usual 
physical disturbances accompanying that process; for, notwith- 
standing its joints continually, though slowly, grew worse lor six 

months, with a marked tissue change and accumulation of pus 
it did not go into a state of decline with the characteristic de- 
crease in weight which usually accompanies active rheumatic 
infection. 

SUMMARY AND CONCLUSIONS. 

There are several phases of this that must be kept in mind. 
First is the danger that may be done by injecting of such sub- 
stances. This is particularly true of ethylhydrocupreinhydro- 
chlorate, which may have a distinct injurious effect upon the 
eyes; and those who read this must be sure not to use it upon 
patients until much more work is done with it. The chaulmugra 
oil compound derivatives show promise of benefit. The experi- 
mental data are entirely inadequate as yet, however, to justify 
its use on patients. 

These preliminary experiments would seem to 
suggest that, means can be developed which will 
effectually assist, by chemical means in the defense 
of the body against the invading streptococcal 
organisms of dental origin or from other sources 
which produce the rheumatic group lesions. 



CHAPTER XXVII. 

THE EFFECT OF RADIATION ON DENTAL PATHO- 
LOGICAL LESIONS. 

PROBLEM: Can periodontoclasia and apical abscess 
and inflammation be cured by various types of radiation? 

EXPERIMENTAL AND DISCUSSION. 

We began our studies on this problem in 1897 and 1898, imme- 
diately after the announcement of the discovery of the Roentgen- 
rays and the acquisition of our first apparatus, which was one of 
the first west of New York City. These were followed by studies 
with radium before the name, "radium," had been given to it, 
and when the material from which the radium was finally iso- 
lated was called "Radio-active substance". I published a pre- 
liminary report on the former in The Archives of Electrology and 
Radiology, March, 1904 ' ; and on the latter in the Dental Cosmos, 
May, 1901 "\ read before the International Dental Congress in 
Paris in 1900. 

The early forms of apparatus for developing Roentgen-rays, 
used tubes that were very soft and which operated on a potential 
represented by a spark gap ranging from a half inch to two inches. 
Many of these tubes required relatively long exposures because 
such a small percentage of the ray had sufficient penetration to 
reach the film, which was the reason for our early researches on 
the development of the triple-coated film which, if I am correctly 
informed, was the origin of the original Seed film which was later 
taken over by the Eastman Co. 

We early discovered that when teeth with fistulae were sub- 
jected to the radiations from these tubes, the fistulae tended to 
close ; that sore teeth became less sore. One of these incidents was 
about as follows : The patient was sent by a fellow-dentist for a 
roentgenogram of a tooth with a fistula which the dentist advised 
should be treated. After our several exposures, taking different 
angles, the fistula closed and the man refused to pay for the roent- 
genograms on the ground that they were not needed, that the 
tooth had cured itself. We, accordingly, established a series of 

336 



CHAP. XXVII EFFECTOF RADIATION ON DENTAL LESIONS 33^ 

investigations to determine what the effect might be on gingival 
infections as well as apical involvements when treated by this 
means. A series of special tubes with lead protectors was made 
to put into the mouth, generate the rays close to the tooth, and 
administer the dosage without raying other tissues. In our first 
group, we so treated a dozen and a hall" patients, about two-thirds 
of whom showed marked improvement when judged by the 
criteria of the flow of pus. 

Enough data are available to demonstrate that we are dealing 
here with a force which, when it is understood, will doubtless be 
capable of lending great aid in the treatment of pathological con- 
ditions and, indeed, is already doing so in the treatment of neo- 
plasms. We must, however, clearly distinguish between those 
changes from normal which develop in tissues as the clinical ex- 
pression of the pathological involvement. In some instances we 
have a very markedly lowered capacity for reaction to irritation. 
Invaded tissues do not have the capacity for defending them- 
selves against the parasitic intruder. Their very lack of vital 
reaction determines the outcome of the warfare immediately at 
the outset, for the condition must go from bad to worse, the or- 
ganism gaining more and more vitality and virulence, as the 
tissue develops less and less capacity for defense. Clearly what 
this tissue needs is something that will boost and support 
its already too feeble capacity for reaction. This we will discuss 
presently. Over against this we have another type of reaction in 
tissue, in which the pathological state expresses itself with abun- 
dant cell proliferation and more than normal reactions, which 
process will include the neoplasms such as the various cancer 
growths and some stages of periodontoclasia, or pyorrhea al- 
veolaris. 

When radium, then, is applied to a neoplasm such as an epithe- 
lioma, it depresses that vital capacity which expresses itself in 
cell proliferation, and, if the dosage is properly adjusted, this 
depression may be sufficient to restore this tissue approximately 
to normal, by destroying or depressing all cells having that ex- 
alted capacity. If, however, this same type of cell depressant is 
applied to tissue whose only safety lies in its capacity to exalt its 
activity to any needed extent to baffle and overcome the invad- 
ing infection, it is like putting the brakes on a wagon which the 
overloaded horse is struggling with his most extreme effort to take 
over the grade. In other words, those forms of radiation, which 



338 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

tend definitely to depress vital function, must not be used to de- 
press function where an exalted function is desirable. 

The type of bacterial flora present in a periodontoclasia pocket 
will indicate very directly and definitely many qualities of the 
environment from which it is taken. To the trained eye familiar 
with the microscope the bacterial culture reveals very definitely 
the type of inflammatory process present. One of the greatest 
mistakes that has been made in the study of suppurative perio- 
dontoclasia, or pyorrhea alveolaris, has been to interpret the cessa- 
tion of the development of so-called pus as a cure of the lesion; 
and this is one of the mistakes that I made in interpreting the 
clinical results produced by my treatment of cases of so-called 
pyorrhea alveolaris twenty years ago, as reported in The Archives 
of Electrology and Radiology, March, 1904 (The Treatment of 
Pyorrhea Alveolaris with the X-rays.). I mistook a depression 
of the tissues, as expressed by their capacity to produce an exu- 
date, as a cure. There is no doubt that some of the conditions 
were definitely benefited, and others were definitely aggravated, 
by that same treatment, for they represented entirely different 
stages of a pathological process, one hyperactive cell reaction, 
in which cases were benefited, and the other, a chronic depressed 
reaction state, in which cases were, doubtless, not only not im- 
proved, but, probably, definitely injured. 

To test this further, I have made a series of studies with the 
mercury vapor arc lamp, to determine its effect upon the clinical 
conditions, as interpreted in the light of our newer knowledge, 
with the result, that there seemed definite evidence of a depres- 
sing effect on cell reaction, which was beneficial in only those 
cases having an exalted reaction state, and was definitely harmful 
in those cases with a depressed reaction state. To test this fur- 
ther, we placed teeth under the skins of rabbits and exposed the 
tissue over the implanted tooth to the quartz mercury vapor 
lamp. In every instance the animals died more quickly with this 
treatment plus the infected tooth, than with the same infected 
tooth without the mercury vapor lamp radiation; and, further- 
more, we found that, whereas, when the rabbits died from the 
presence of the infected tooth alone, there was found all about 
the tooth an exudate carrying an abundant quantity of leuco- 
cytes; but when the rabbit was exposed to the radiation for fifteen 
minutes a day as we had been exposing our patients, there was 
found about the tooth practically a pure culture of streptococci 



CHAP.XXVU EFFECT OF RADIATION ON DENTAL LESIONS 

with exceedingly few leucocytes; and. furthermore, when rabbits 
were exposed to the radiation w ithout the presence of the infected 
tooth, we found that the radiation produced a definite depression 
of the leucocytes of the blood. 

These studies strongly urge the establishment of researches 
which will adequately determine, first the reaction effects of the 
rays of various angstrom units, and second, a very careful differ- 
entiation between an exalted and a depressed cell activity in the 
various pathological states with which we are concerned. It 
would seem most unwise that routine clinical application should 
be undertaken before these fundamental problems shall be worked 
out. Some phases of this question will be discussed in the next 
chapter. 

I have undertaken to apply rays of an angstrom unit between 
300 and 1200 from mercury vapor arc in the treatment of perio- 
dontoclasia. One of the cases selected is shown roentgenographical- 
ly in Figure 160. This was a case of chronic periodontoclasia, 
with much destruction of tissue and loosening of the teeth. The 
method of determining the presence or absence of improvement 
was by testing the hydrogen-ion concentration of the saliva, the 
bacterial types, and the quantity of their growth in the pockets, 
and the tightening of the teeth, with the improvement in the ap- 




FlGURE 160. A CASE OF PERIODONTOCLASIA TRKATED WITH ULTRA- 
VIOLET RAYS FROM A QUARTZ MERCURY VAPOR ARC. A, IS WITHOUT 
GUTTA-PERCHA POINTS IN POCKETS, AND B WITH. NOTE HOW DECEIVING 
A IS. 

pearance of the gingival tissue. As judged by these criteria, there 
was but slight, if any, improvement; and, particularly, when 
judged by the bacterial flora, which is one of the best indications. 
In the second view' in B, flexible gutta-percha points are placed 
in the pockets between the teeth; and the advantage of their 
use is very apparent, for it will be noted that in A the pocket 
between the two molars does not appear to be nearly as deep as it 
is shown to be by the passage of the flexible points, which stresses 



340 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

what so many have learned to their chagrin, that the conditions 
were very much worse than they were supposed to be, when 
judged simply by the roentgenogram. The dosage given was 
fifteen minutes with a quartz applicator, twice a week, for about 
ten weeks. If improvement would not be produced in that time, 
the treatment would not justify its continuance in our judgment. 
The slight improvement in the types of bacterial flora was tem- 
porary and tended to return to its former type quite early after 
the cessation of the treatment. 

In order to determine more exactly what the effect of such 
treatment would be, I placed an infected tooth beneath the skin 
of a rabbit, and treated same with the quartz mercury vapor arc 
lamp by flooding the tissues over where the tooth was planted 
beneath the skin, with these rays for fifteen minutes a day for 
two days, the day of the implantation and the day following. On 
the third day it was chloroformed. It was our belief that the tis- 
sue broke down more rapidly, and tissues became a prey to the 
infection more speedily, than when this tooth and other teeth 
were planted beneath the skins of other rabbits. There was also 
a very marked decrease in the number of leucocytes present in the 
fluid surrounding the infected tooth. The rabbit was posted on 
the third day, at which time it had lost 130 grams, or 10 per cent, 
and showed at necropsy, subcutaneous gangrenous necrosis, with 
edema of the underlying tissues. There was marked hyperemia 
of the thyroid, spleen, and kidneys. 

I, therefore, decided to make observations on the effect of these 
radiations on a normal rabbit. Its blood was studied prior to its 
exposure to the rays and then frequently observed during the 
treatment. Results are shown in Figure 161, which records the 
various elements from day to day. It will be noted that there was 



EFFECT OF RADIATIONS ON BLOOD OF NORMAL RABBIT 



Date 


Hemo- 


Erythro- 


Leuco- 


Poly- 


Lymphocytes 


Baso- 


Mono- 


globin 


cytes 


cytes 


nuclears 


Large 


Small 


phils 


nuclears 


*3- 8-23 


85 


7,000,000 


7,200 


59 


8 


24 


1 


8 


*3- 9-23 


85 


4,300,000 


10,800 


64 


16 


17 




3 


3-10-23 


85 


4,550,000 


7,800 


53 


12 


26 


2 


7 


3-12-23 


80 


4,770,000 


4,600 


40 


11 


43 


2 


4 


*3-14-23 


85 


5,150,000 


6,000 


36 


8 


55 




1 


*3-15-23 


85 


5,650,000 


9,900 


35 


8 


54 


1 


2 


*3-19-23 


80 


5,800,000 


5,400 


43 


6 


50 




1 


3-23-23 


80 


5,050,000 


7,800 


41 


11 


46 


2 




* The 


1 rabbit 


received 15 m 


inute trea 


tments foil 


owing the bloo 


i counts 





Figure 161. 



Cl!\r \\\ll EFFECT OF RADIATION ON DENT A] LESIONS 



341 



a decrease in the percentage of polymorphonuclear cells, with a 
marked increase in the small lymphocytes. In our studies with 
infected teeth planted beneath the skins of rabbits, and when cul- 
tures are inoculated of dental origin, there often develops a de- 
crease in polymorphonuclears and an increase of lymphocytes as 
part of a developing leukopenia, which depression of leucocytes 
always indicates a poor defense progressing toward death, which 
usually cuts short the experiment in a few days after its develop- 
ment. A very important effect of the radiation on this rabbit is 
expressed in the change in ionic calcium of the blood, as shown 
in Figure 162. On the 8th, this was 10.4 mgs. per 100 cc., approxi- 
mately normal. The first reaction to the stimulation of a single 
exposure increased the ionic calcium to 11.13; and on the 13th, 
this had changed to a distinct pathological state of 8.27. Another 
very striking feature of this change relates directly to calcium 
metabolism; for the combined calcium of the blood on the 8th 
was 1.7; on the 9th, it had increased to 3.7; and on the 13th, to .5. 



EFFECT OF RADIATIONS ON BLOOD CALCIUM OF NORMAL RABBIT 



Date 


Calcium 

plus 
Thrombin 


Thrombin Calcium 
Equivalent Ionic 


Calcium 

plus 
Combined 


Combined 
Calcium 


3- 8-23 
3- 9-23 
3 13-23 


17.60 
19.00 

17.20 


7.199 10 401 
7.866 11.134 
8.923 8 277 


12.13 

14.878 

8.793 


1.729 

3.744 

.516 



Figure 162. 

I have made a number of studies with radium, and have found 
it very difficult to be sure that I was properly interpreting the 
results because of the difficulty of knowing the proper dosage, for 
just as a little strychnine may be good, and a very little more may 
be very harmful, just so a proper dosage of radium or otherwise, 
may be distinctly beneficial, and just a little more distinctly 
harmful. I am, therefore, withholding these studies until I have 
more data, for it is exceedingly difficult properly to control and 
limit the effects of radiation to the pathological tissue, it being so 
intimately related, anatomically, to normal tissue; and the very 
treatment which may be a benefit to the former, may, at the same 
time, be harmful to the latter. If we put a medication into a 
pocket of periodontoclasia, its action may be quite completely 
limited to the tissues with which it comes in contact and those 
very closely adjacent. Radiations, on the contrary, pass not 



342 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

only through the adjacent tissue, but through the entire body in 
many instances, and the dosage and application are not within 
easy control. For this reason we have undertaken to use the 
radiations from silver chloride in colloidal suspension but, while 
these have bactericidal effects, and will even pass through a glass 
tube, we have not found that placing either the tooth contain- 
ing a tube of this material, or the tooth saturated with it, was 
sufficiently less harmful, when planted beneath the skin, to as- 
sure us that it was an efficient germicide. It is a favorable field, 
however, for investigation. 

There are many reasons to believe that great benefit will ulti- 
mately come from an adequately intelligent use of radiations of 
various lengths, when properly selected and adapted to the needs 
required. We now know that neoplasms represent a diverted cell 
function, which, in the proliferative types, express an overactive 
state ; and any force which tends to depress, will thereby suppress 
the proliferation. For this the very short rays of the x-ray and 
radium tube are most efficient. Similarly, we know that radia- 
tions of the range of three hundred to six hundred tend to produce 
beneficial changes in rickety conditions; and again, we know that 
whereas animals will die of vitamin deficiency when fed on dried 
peas, for example, they will be promptly restored by being fed on 
these same dried peas that have been allowed to sprout and been 
exposed to sunlight. Similarly, the algae of the sea, through their 
exposure to the sun's rays, have become immense storehouses 
for vitamins, which latter are stored in the livers of the fish, and 
hence are largely in use, medicinally, in cod liver oil. It is also 
general knowledge that sunlight is necessary for health. The 
rickety children in a smoky city will recover by being moved to 
the sunlight of the clear country, even though retained on the 
same diet. Not only is this true, but just as the distance from the 
equator is lengthened, mankind is required to use more of the 
vitamin storage foods as he approaches the shorter days and 
hence decreased sunlight, which is the reason that Labradorians 
and Arctic inhabitants live so much on the fats and oils of fish. 

When we come to know the true nature of disfunctions of vari- 
ous tissues and organs, we can then judge wisely what type of ray 
should be used to improve its condition, and interpret wisely what 
constitutes an improvement and what an apparent improvement 
but an actual injury. An illustration of the latter can clearly be 
seen in the misconception regarding the significance of a closing of 



CHAP XXVII BFFE( I OF RADIATION ON DENTA1 LESIONS 343 

a dental fistula alter exposure to Roentgen-ray, and the cessation 
of the so-called pus from periodontoclasia from exposure to Roent- 
gen-ray and other radiations. I am not decrying these means, hut 
1 am trying to point out that we must understand their funda- 
mental pathology before we can treat them intelligently or inter- 
pret wisely the results of our efforts. This, therefore, is a field 
that represents a crying need for exhaustive research on the basis 
that will be competent to bring about dependable and properly 
interpreted results. 

CONCLUSIONS 

The results of these studies suggest to me the following: 

{I.) That these three forms of radiation namely, 
Roentgen-ray, radium radiation, and ultraviolet as 
generated from mercury vapor and quartz tube- 
have definite effect on cell resistance to prolifera- 
tion, and thus directly upon tissue reaction expres- 
sions such as pus, bacterial invasion, and granula- 
tion. 

(2.) That some of these forces are, apparently, 
definitely harmful; that others are, apparently, 
definitely helpful. 
Our interpretations of these phenomena are given in Chapters 
45 to 56. 



CHAPTER XXVIII. 

GINGIVAL INFECTIONS, THEIR PATHOLOGY AND 

SIGNIFICANCE. 

PROBLEM: Are the present theories regarding the etiol- 
ogy of periodontoclasia, or so-called pyorrhea alveolar is, cor- 
rect? 

EXPERIMENTAL AND DISCUSSION. 

I cannot find in all of medicine, whether in general medicine 
or in the specialties including that of dental medicine, instances of 
very common diseases which have so completely baffled explana- 
tion or which contain so many paradoxes as has this disease. 
In the minds of the majority of the members of the dental and 
medical professions, and as well, and naturally so, in the minds of 
the members of the laity, this disease is thought of largely as a 
true infection process. The imperative necessity for brevity in 
these reports precludes the possibility of presenting, herewith, a 
history of the theories as to its etiology. For such, I would refer 
to various books on general or dental pathology. 

Lately, it has come to be recognized and thought that irritants 
play an important part, and that their removal becomes a funda- 
mental part of the treatment of this disease, though their removal 
does not explain its etiology. Similarly, traumatic occlusion has 
come to be recognized as an irritant and, like a foreign substance, 
must be corrected. One of the advanced thinkers in the etiology 
of this disease, Eugene Talbot, has advocated that the supporting 
structures of the teeth are transient tissues and, as such, tend 
readily to be absorbed, which accounts for the fact that, in the 
presence of bacterial invasion and irritation, that process which 
is part of senility, sets in early. In his paper entitled "The 
Etiology and Treatment of Interstitial Gingivitis," 
he states : 

"When we consider the peculiar endotransitory nature of the 
alveolar process, degeneration of tissue is the natural result. At 
the senile period when the excretory organs are diminishing in 

1 s See bibliography. 

344 



CHAP. XXVIII PATHOLOGY OF GINGIVAL INFE( rIONS 345 

activity and in disease, vital resistance is at its lowest ebb, metab- 
olism is diminished, and degeneration and absorption of the 
alveolar process is in active operation. As age advances, the 
destruction of bone is a natural normal pathologic process". 

About twenty-five years ago, I started a quite intensive study 
of this disease, and found that every time I approached the prob- 
lem through the doorways of the available theories, I ran into a 
network of contradictions and confusions which persuaded me 
that there were some things fundamental, of which we were not 
as yet appraised, and which were the most important factors in 
the etiology of this disease. And since the workers in this field 
had apparently not succeeded by approaching from the regula- 
tion doorways, I decided to make a new approach namely, by 
way of an exhaustive analysis of the clinical data and a careful 
examination of the characteristics of the individuals presenting 
with that affection, and relating these data to the blood and saliva 
chemistry and bacteriology. Accordingly, as a part of the sus- 
ceptibility study to streptococcal infections, we have carried on 
an extensive study of the characteristics of all individuals with 
regard to their susceptibility to gingival and alveolar infections. 
There soon appeared in these studies, either a great anomaly or a 
great truth. For a long time we could not accept it as a funda- 
mental truth ; it was so paradoxical to the conception we had en- 
tertained. 

In discussing the clinical phase of this group of affections, I 
have presented much data which are necessary for our approach 
here, and to save repetition, I will refer back to those chapters for 
many references These are found particularly in Chapters 4, 
8, and 10. 

Figure No. 44 shows the result of a series of studies that was 
made several years ago, and tabulated three years ago, which 
showed that, when patients with or without susceptibility to 
rheumatic group lesions, were divided into progressive groups in 
accordance with the degree of that susceptibility, a very impor- 
tant change took place with regard to their susceptibility to peri- 
odontoclasia. In Group No. 1, absent susceptibility, the per- 
centage with periodontoclasia was 23; Group No. 2, acquired 
susceptibility, 33 r ( ; Group No. 3, very mildly inherited suscep- 
tibility, 25 r f ; Group No. 4, moderately strong inherited suscep- 
tibility, r ( ; and Group No. 5, very strong inherited suscepti- 
bility, 0^ ;whereas, in these various groups extensive caries was 



346 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

as follows: Absent susceptibility, 51%; acquired susceptibility, 
91%; mild inherited susceptibility, 81%; moderately strong in- 
herited susceptibility, 88%; and very strong inherited suscepti- 
bility, 100% ; and the presence of locked dental infection tended 
to increase from 58% absent susceptibility, 75% acquired suscep- 
tibility, 44% mildly inherited susceptibility, 75% moderately 
strongly inherited susceptibility, to 86% very strongly inherited 
susceptibility. 

In order that we might thoroughly check so great a new truth, 
if such it be, before presenting it, and with the most earnest de- 
sire not to permit an error to be presented, we have refrained for 
several years from announcing this important discovery, await- 
ing a satisfactory mass of data that would either establish or dis- 
prove it. Accordingly, a new corps of assistants has tabulated a 
new group of findings, not knowing either the results of the former 
studies in this regard, or even that they had been made. These 
results are shown in Figure 85 of Chapter 10, the latter chart giv- 
ing as follows: Absent susceptibility 40; acquired 33; inherited 
one side mild 33; two sides mild 20; one side strong 20; two sides 
strong 0. 

This was further shown in Figure 87 which reveals that, when 
individuals are divided into three groups — absent, acquired, and 
inherited (the latter of all grades of inheritance) — , the percent- 
age of individuals affected with periodontoclasia in the group 
recorded as absent susceptibility was 48; acquired susceptibility 
29; and inherited susceptibility 16. 

All observing dental clinicians have noted for decades that 
teeth with extensive gingival infection do not suffer carious de- 
struction. This paradox seems to hold an important key to the 
interpretation of much of dental pathology. 

An extensive study of the bacterial flora found in periodon- 
toclasia infections has demonstrated that there has been a great 
divergence of opinion as to the causative invading organisms. 
Of the workers, Hartzell and Hendersy have stressed the impor- 
tance of streptococci, while most workers, both early and late, 
have noted the presence of spirochetes and fusiform. The great 
drawback in the study of this disease has been found in the fact 
that the characteristic bacterial growth cannot be produced in 
artificial media. Some of the workers have been able to grow a 
few of the organisms. Our studies have shown a quite definite 
tendency to grouping of bacterial types of infection: those in 



CHAP XXVIII PATHOLOGY OF GINGIVAL INFECTIONS 347 

which fusiform and spirochete abound almost exclusively; those 
in which spirochete abound almost ly exclusively; and tho» 
where these two types are very scarce, if not almost entirely 
absent, with an abundance of short rods, staphylococci, strepto- 
cocci. 

In order to determine the significance of the important data 
revealed in the relationships between gingival infections and the 
other outstanding clinical conditions namely, presence or ab- 
sence of dental caries, presence or absence of systemic involve- 
ment, types of local dental pathology — we have related each of 
these conditions as found in various individuals to the serological 
and chemical changes in the blood, saliva, urine, etc., of those 
individuals. 

In Figure 85, Chapter 10, I have shown that tendency to gingi- 
val infection is, in large measure, in proportion to defensive activ- 
ity, and. therefore, in proportion to absence of rheumatic group 
lesions, these figures progressing from 40 per cent of the individ- 
uals with absent susceptibility having periodontoclasia! processes, 
33 per cent of the acquired group, 33 per cent inherited one side 
mild, 20 per cent inherited two sides mild, 20 per cent inherited 
one side strong, and per cent inherited two sides strong. I do 
not present these figures with any thought that they are exact, 
but, when taken from such a large number of cases and from 
several groups by different individuals, the fact that the result 
is, in general, constant, suggests that they are relatively correct. 
We do not yet know the significance of many of the new data that 
we are here presenting, but it is a matter of exceeding interest 
and of undoubted importance, that patients with active periodon- 
toclasia without exception, in our experience, have been found to 
have a high ionic calcium, in the order of 11 to 12.5 mgs. per 100 
cc. of blood, as compared with 10 to 10.5 for our accepted normals. 

An analysis of this clinical data reveals the remarkable fact 
that in some way the presence of an active defense against strep- 
tococcal infections, in so far as the absence of rheumatic group 
lesions is concerned, is directly related to the clinical expression 
which we find as periodontoclasia, or pyorrhea alveolaris, in cer- 
tain of its stages. It is not an accident that so many people with 
such extensive gingival suppurative processes are apparently in 
excellent health. 

For determining the factors involved in the lesion known as 
periodontoclasia, or pyorrhea alveolaris, we have undertaken to 



348 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

discover the contributing influence of each. An analysis of these 
suggests that mechanical irritation, bacterial invasion, and de- 
fensive reaction, all play important parts. In order to determine 
the relative importance of all of these we have treated different 
groups in different ways. In the first group no other means has 
been used than the mechanical removal of irritation; in the sec- 
ond group no other means than local bactericidal treatment; in 
the third group systemic bactericidal treatment; in the fourth 
group the changes in the peridental tissues where the individual's 
defense had been lowered by inflammatory and other causes; the 
fifth group artificial stimulation of gingival tissues. These showed 
as follows: That in the early stages of periodontoclasia the 
simple elimination of the substances producing mechanical irri- 
tation, thus removing the primary irritant which caused the in- 
flammatory reaction, entirely removed the periodontoclasia, or 
pyorrhea alveolaris. In the far advanced conditions the removal 
of the mechanical irritant made much less improvement, and in 
some cases very little. In the series of cases studied to show the 
effect of local bactericidal treatment we have many illustrations 
which reveal a marked improvement in the clinical conditions 
with no other treatment. The effect of systemic bactericidal 
treatment, in which case the injection of emetin and succinimid 
of mercury was used, showed marked improvement in local clini- 
cal symptoms even though the mechanical irritant was not dis- 
turbed. 

Another series of studies was very illuminating. These were 
conducted in 1898 to 1904 on the use of the Roentgen-ray in the 
treatment of periodontoclasia, which we have discussed in the 
preceding chapter and which was published in The Archives of 
Electrology and Radiology, March, 1904. ' In those studies I 
found that Roentgen radiations tended to depress the reaction 
capacity of the tissue to a marked extent. 

Inasmuch as the local bactericidal treatment and the mechani- 
cal removal of the irritants each produced practically complete 
removal of the local oral symptoms, it suggested very strongly 
the great need for a research upon the problem of the improve- 
ment of germicidal procedure. For this purpose a series of re- 
searches has been carried on for several years, at one time taking 
practically the entire time of a trained bacteriologist for one 
year, to ascertain the drugs and chemicals that were most efficient 
in depressing the type of bacterial growth which tends to develop 

1 See bibliography. 



CHAP XXVIII PATHOLOGY OF GINGIVAL INFECTIONS 349 

m the mouth, in which there isa marked susceptibility to develop- 
ment of periodontoclasia, or pyorrhea alveolaris. These re- 
searches themselves would fill a volume and will only be sum- 
marized here to present the important results. Their application 

is made in extended detail in a later presentation. 

The following types of drugs were found most efficient, though 
some were not suitable because of" undesirable qualities: Mer- 
curic nitrate (This discolors the teeth in time and has the possi- 
bility of systemic irritation.); chaulmugra compounds; chlorine 
compounds; zinc compounds, particularly the chloride and sul- 
phocarbolate; silver compounds. 

In the group of individuals studied by mechanical stimulation 
of gingival tissues, a very marked change in the local clinical con- 
ditions was shown. With the improvement of the circulation, 
there was a marked decrease in both the bacterial growth and 
development of exudate and also in the hypertrophy and con- 
gestion, notwithstanding the fact that the massage was done 
against tissues, which were being pressed against rough deposits 
on the necks of the teeth, the effect of which was to lacerate and 
injure these tissues. Notwithstanding this latter fact, the im- 
provement was very marked. 

Since it is demonstrated that marked beneficial results may be 
secured by each and all of the methods of procedure, though some 
more than others, it becomes apparent that the utilization of 
those means, which are most easily applied, will in many cases 
be all that is necessary to prevent the development of this clinical 
condition. This involves first the mechanical removal of irrita- 
tion; second, the use of bactericidal means for depressing the type 
of organisms which develop in this condition; third, the use of 
mechanical stimulation to prevent the passage of those fluids 
which tend to nourish the bacteria from the surrounding tissue 
into the pockets of periodontoclasia and to provide the rapid ex- 
change of fluid in the involved vascularized tissues in order to 
bring new defensive factors and carry away waste products, the 
use of substances producing radiation in order to reduce to nor- 
mal the reaction capacity of the tissue exalted as a part of the 
infective process. 

In the chapters on Tooth Medication, Radiation, and Chemo- 
taxis, I have reviewed the effects of the use of substances produc- 
ing radiation for reducing bacterial growth and exalted tissue 
reaction. In a later presentation I will give special formulas for 



350 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

the development of tooth powders and methods for their use, 
suited to each of the different types of extreme oral conditions, 
such as tendency to caries, tendency to gingivitis, periodonto- 
clasia, pyorrhea alveolaris, etc. These are so simple that they 
may be put up by any good druggist and should be available to 
humanity at small cost; and if used sufficiently intelligently and 
faithfully as indicated, will almost completely prevent the de- 
velopment of the disease known as periodontoclasia or pyorrhea 
alveolaris. 

It is most important that we urge the reader to keep in mind a 
very great difference in the type of gingival infection which is 
typical of the active suppurative type in its early stages, which 
responds readily to the removal of local irritants and to stimula- 
tion, from the chronic non-suppurative poorly reacting condi- 
tion. In this discussion we are referring distinctly to the early 
active process which has an entirely different pathology from the 
other types which represent the ravages of the former active proc- 
esses, carrying it over into a changed systemic condition. 

When we relate the following factors — namely, the relative 
extent of absorption of supporting structures, whether apical or 
gingival, the presence or absence of systemic involvements, the 
absence or presence of dental caries, the ionic calcium of the 
blood, the ionic calcium of the saliva, the alkali reserve of the 
blood, the alkali reserve of the saliva, the uric acid content of the 
saliva, the uric acid content of the blood, urea nitrogen of the 
saliva, urea nitrogen of the blood, — we find certain groups of 
conditions are, practically, invariably associated. The individual 
with the high defense has a normal ionic calcium of both blood 
and saliva. It is apparent, then, that this quality of the presence 
or absence of gingival infection with a given irritant is related 
directly to calcium metabolism. When we make a careful study 
of the characteristics of the various physical states which modify 
calcium metabolism most, we find that just in proportion as that 
individual is able to maintain a high or abnormally high ionic 
calcium balance of the blood, in that same proportion his gingival 
supporting tissues tend to be absorbed easily in the presence of 
irritation. 

This research has been planned to establish, if possible, what 
some of the direct variable factors are in connection with this 
susceptibility to destruction of the alveolar bone in these cases. 
A careful study of the saliva reveals, and that readily, that it is 



CHAP \\\lll PATHOLOGY OF GINGIVA! INFECTIONS 351 

more alkaline in individuals with a marked tendency to periodon- 
toclasia. A more exact study of the hydrogen ion concentration 
of the contents of the pockets of periodontoclasia shows that in 
the active condition it is very alkaline, reaching as high as 7.7 
whereas the hydrogen ion concentration of the blood is 7.3. 

In another chapter we have noted the important clinical fact 
that the sockets ol" extracted teeth, which teeth were involved 
with acute periodontoclasia, tend to heal with great ease and 
rapidity, seldom requiring a treatment following the extraction. 
A blood clot is readily formed. It is well organized. It becomes 
vascularized by the development of embryonic blood vessels in 
the clot, and its socket heals without pain and without the clot's 
ever breaking down; whereas, on the other hand, a socket of a 
tooth with marked condensing osteitis without a tendency to in- 
volvement tends to have its blood clot break down, readily be- 
comes painful, and in many cases develops what is clinically 
termed "dry socket", which condition is characteristic. An 
analysis of the saliva of this type of patient shows a lower degree 
of alkali reserve; his blood shows a lower ionic calcium; and, im- 
mediately, we are dealing with two distinct types of individuals. 
This problem of the postoperative treatment of the sockets of 
various types of individuals will be discussed in a later presenta- 
tion. 

A careful microscopic examination of the contents of these two 
different types of sockets has revealed an important new group of 
facts, which are so constant, that they become immediately 
definitely diagnostic. The leucocyte found in the socket of the 
tooth extracted with periodontoclasia is largely a polymor- 
phonuclear with several lobes. The cytoplasm is filled with 
granules which are readily disclosed either by the dark field or 
direct illumination, and with certain types of vital stains; but 
most important, these polymorphonuclears show a rapid motility 
of these granules. Many of these cells contain bacteria which are 
in relatively small quantities outside the leucocyte, in proportion 
to the clinical picture found in the other type of socket, which 
latter, in contrast to the former, has few leucocytes with actively 
motile granules, relatively few phagocyting leucocytes, and 
larger numbers of organisms outside these cells. 

We have, then, a direct measure in this process of the activity, 
and since a socket shows, under treatment, these highly active 
granular polymorphonuclears, it usually goes on readily and 
rapidly to complete healing process. So far as we know, this 



352 DENTAL INFECTIONS, ORAL AND SYSTEMIC- RESEARCHES— VOL. I 

phenomenon has never been reported. We have not been able to 
find a reference to it in any literature or by correspondence with 
our leading hematologists. 

A closer study reveals that, if in a socket of the second type- 
namely, without the presence of this large number of character- 
istic granular leucocytes whose granules are highly motile — we 
place an ionic calcium, as, for example, calcium chloride together 
with bicarbonate of soda, within a few hours the pain subsides, 
the type of leucocyte changes, and the type of socket has been 
changed so that it starts immediately on the process of repair. 
This has led us to a careful analysis of the relationship between 
the process of decalcification and ionic concentration of calcium, 
and these in relation to the alkali reserve of the blood. 

A further analysis of the various charts in which we have 
compared the clinical expressions, structural changes, and chemi- 
cal analyses, we find that in those cases where the suppurative 
process was most active, the content of the pockets of periodon- 
toclasia were most alkaline, the ionic calcium of the blood high 
normal or above normal, blood sugar higher than normal, trabec- 
ular differentiation of alveolar bone very marked, caries low or 
zero, tissue repairing qualities excellent, inflammatory response to 
mechanical irritation acute, etc., all existing in an individual with 
every evidence of a high defense to rheumatic group lesions such 
as complete absence of heart involvement and rheumatism. In 
sharp contrast to the preceding, we find that the individual who 
has a marked susceptibility to rheumatic group lesions strongly 
tends not to have pockets of periodontoclasia even in the presence 
of irritation sufficient to produce same, such as gold crowns, food 
packs, etc. In him the ionic calcium of the blood is below nor- 
mal, blood sugar not above normal, trabecular differentiation 
diffuse and not marked, caries high, tissue repairing qualities— 
particularly of alveolar bone — poor, inflammatory response to 
mechanical irritation subacute or low, etc. 

This relationship between the clinical, serological, and chemi- 
cal factors, has suggested to me that these must be related as 
cause and effect; and, accordingly, a series of researches is being 
made to ascertain, if possible, the mechanism of this reaction. 
We are, accordingly, taking a large group of extreme cases of each 
of the different types and carrying out these studies in further 
detail with especial reference to the relationships between the 
alkali reserve of the blood and the clinical symptoms, such as the 



CHAP XXVII] PATHOLOGY OF GINGIVA] INFECTIONS 

destruction of the gingivae, the peridental membrane, and the 

alveolar bone. 

From these data it is shown that as the alkali reserve goes down 
and the ionic calcium goes up. there is a marked tendency to 

acute inflammatory reaction to irritations, with necrosis of soft 
tissues, and absorption of alveolar bone; and where the alkali 
reserve is not below normal and the ionic calcium not up to nor- 
mal, there is not marked reaction to irritation of gingival tissues 
and but little absorption of alveolar bone. In Chapter 1 1 I have 
discussed the relationships involved in these phenomena in detail. 
It is there shown that one of the system's most difficult and exact- 
ing operations is the maintenance of the normal hydrogen ion 
potential of the blood, which is made possible only by an ample 
reserve of buffers to take care of sudden increases in acidity or 
alkalinity, particularly the former, called the alkali reserve of the 
blood. For ordinary purposes in normal individuals this can 
readily be done by drawing upon the compounds within the blood 
itself together with respiration. This becomes increasingly diffi- 
cult as that alkali reserve is reduced ; and since the mechanism of 
defense is made very active, doubtless by hormones, but also 
very largely by a high ionic calcium of the blood, catabolic and 
physiologic processes are carried out with great ease and rapidity. 
For the process of defense against infection, Nature has provided 
the flooding of the parts with an alkaline plasma. The mechanism 
is available to create the alkalinity of the fluids bathing the parts 
in periodontoclasia, but the reserve supply of buffers is so greatly 
reduced, that Nature must resort to other sources of material for 
producing this alkaline medium. She, accordingly, must have 
some means for producing an alkaline medium in the absence of a 
low alkali reserve in the blood. In order to determine this reac- 
tion we have carried out the following research : 

Since the hydroxyl ion is increased in the saliva of individuals 
with a marked susceptibility to periodontoclasia, it should be 
possible to determine what substances have taken part in that 
process by comparing the concentration of the various constitu- 
ents in pockets of periodontoclasia and in the saliva itself, the 
latter furnishing the medium surrounding the environment, the 
former a mixture of the latter with the products of the reaction 
within the pocket. To determine this I have made a series of 
studies in which we have compared the following elements in the 



354 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

pockets of periodontoclasia and in the mixed saliva of the mouth 
and compared them with the blood chemistry. Since the blood 
and saliva must largely furnish the constituents for the pocket of 
periodontoclasia, it immediately becomes apparent that any 
marked increase in any element found in the pocket of periodon- 
toclasia over that of the blood and saliva will indicate that there 
has been some other source. These have shown that the total 
calcium of the pocket of periodontoclasia is much in excess of that 
of either the blood or saliva. This cannot be accounted for on the 
basis of concentration. It will be noted that as the OH ion in- 
creases in the production of alkalinity, there is an increase in the 
excess of calcium over that of either the saliva or blood. There is 
also an increase in the phosphorus. This immediately suggests 
the question, Where do these substances come from to make this 
excess? When we compare the relationship between the calcium 
and phosphorus of the saliva with those elements in the blood of 
individuals without periodontoclasia, we find that it is not nor- 
mal for those substances to appear in the saliva in greater concen- 
tration than their existence in the blood, and that their concen- 
tration increases as the clinical expression of periodontoclasia. 
It is, therefore, apparent that this alkalinity is accomplished by 
an increased cell activity with an osteolysis partly the result of 
the increased concentration of calcium ions, which activity has 
torn down the alveolar structure to secure neutral calcium phos- 
phate in the absence of the normal alkali buffers of the blood, 
whose normal function would be to supply this demand. 

It frequently occurs that patients with profuse spirochete in- 
fections, are suffering from marked toxemia, with progressive loss 
of weight. A typical illustration of such a case is shown in Figure 
186 of Chapter 35. This patient had lost eighteen pounds in 
weight in three weeks; and immediately following the treatment 
of his gums, the patient gained ten pounds in two weeks. 

Since the preceding researches on the etiology of periodonto- 
clasia, or so-called pyorrhea alveolaris, have demonstrated the 
important role of each alkali reserve of the blood, alkali reserve of 
the saliva, ionic calcium of the blood and ionic calcium of the 
saliva, it is important to determine, if possible, some of the mech- 
anisms of the contributing factors to this process. Our mi- 
croscopic studies referred to have revealed the presence of large 
numbers of a type of polymorphonuclear containing very actively 
motile granules. This leucocyte is also very abundant in the 



CHAP. XW HI PATHOLOGY OF GINGIVAL INFEC I IONS 

sockets of extracted teeth which are repairing rapidly and satis- 
factorily, but greatly diminished or absent in sockets healing 
slowly or with pain or necrosis of tissue. As stated previously. 
it seems certain that these cells play a very important part, since 
they are present in both these conditions which represent in a 
sense opposing states, for one is rapid repair and building up of 
tissue, and the other is the tearing down of tissue. The same 
socket, from which the tooth with periodontoclasia is removed 
without any treatment whatever, practically always heals with 
exceeding rapidity and practically always without pain, necrosis, 
or infection. The placing of a foreign irritant, such as a piece of 
metal, in this same tissue does not produce the same type of re- 
action, either as expressed in exudate or tissue change, as does 
the presence of this type of tooth, mere removal of which com- 
pletely reverses, or at least modifies, cell activity. 

Normal adult tissue does not tend to proliferate after an organ 
or structure has reached its normal size. During the growing 
period, all tissues tend to multiply at a physiological rate con- 
stituting growth, which process is progressively slower with age 
until the adult development is reached. It is as though an arrow 
were shot from a bow, or a bullet fired from a gun. Each has its 
maximum velocity at the beginning of the flight. The velocity 
slackens at a definite rate; the period of rest is reached. In nor- 
mal tissues there is no tendency to take up the condition of pro- 
liferation until conditions become abnormal. If tissue be injured, 
there is an immediate reaction in the local circulation, the capil- 
laries distend, leucocytes come to the parts in large numbers, 
plasma exudes, and in proportion to the extent of the injury the 
reaction may include the entire body of the organism. White 
connective tissue cells rapidly begin to multiply; embryonic blood 
vessels extend from the capillaries; and after a clot has been 
formed and is not infected, this vascularization and rapid tissue 
generation extends into and throughout the clot. Finally, the 
tissues are rebuilt, proliferation ceases, rapidly formed connective 
tissue will be slowly rebuilt with the normal type of tissue of the 
part, and again Nature settles down to her normal, and there is 
no more cell proliferation. 

This same process takes place when a tooth is extracted from a 
normal individual and is precisely the procedure with the repair 
of the socket after the extraction of the tooth. This, however, 
does not occur in those individuals with a low calcium and with a 



356 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

marked susceptibility to rheumatic group disturbances. This is 
doubtless partly occasioned by the fact that, the tissue, which 
has to take part in the repair, is distinctly different in the two 
types of individuals. In those with high defense there is little 
sclerosed bone, the medullary spaces between the trabecular are 
normal in size, and the alveolar bone is well vascularized. We 
have shown from our clinical studies that, one of the most con- 
spicuous differences between these two types in their healing 
process, is in the absence in the latter, and the presence in the 
former, of a particular type of leucocyte, a polymorphonuclear 
with highly motile granules. 

SUMMARY AND CONCLUSIONS. 

From these data we are led to conclude : First, that the funda- 
mental factor in periodontoclasia, or pyorrhea alveolaris, is not 
a specific infection; second, its etiology is in a direct way related 
to the presence or absence of susceptibility, by both being symp- 
toms of a definite systemic condition; and third, the disease we 
have known as periodontoclasia, or pyorrhea alveolaris, is in 
some very definite way related to defensive factors. Since all of 
these researches combine together to furnish the new interpreta- 
tion, it becomes necessary to reserve that interpretation for the 
chapters assigned to that important part of this presentation. It 
will be found in Chapters 45 to 56. 

We would briefly summarize our interpretation of these data 
as follows: 

(1) Inflammatory processes of the tissues about 
the teeth are a direct expression, and therefore a 
measure of the vital capacity for reaction of that 
individual to an irritant, during those stages of 
these lesions, characterized by an abnormally high 
vital reaction. 

(2) The individual, who has had this ca- 
pacity for a very active reaction to the presence of 
irritants, may pass into a condition or state in 
which he or she has lost that high defensive factor, 
at which time several changes develop including 
a cessation of the absorption of alveolar bone, a low- 
ering of the alkalinity of the periodontoclasia 
pockets, a change in their bacterial flora, all of 
which may provide under these later conditions 
a focus for systemic infection of the most danger- 



CHAP JCXVIU PATHOLOGY OF GINGH \l i\i I a riONS 357 

0118 type, though they may have ceased either to 
have evidence of local inflammatory disturbance, 
or exudate as pus. 

(3) To the ordinary observer, lay or professional, 
these two very dissimilar states are considered to be 
similar or identical though they are potentially very 
different. 

(4) These different peridental expressions or re- 
actions to irritations are accompanied by, and 
doubtless related to, changes in the ionic calcium 
of the blood. 



CHAPTER XXIX. 
ETIOLOGICAL FACTORS IN DENTAL CARIES. 

PROBLEM: What are the dominant etiological factors 
in dental caries? 

INTRODUCTION AND DISCUSSION 

We have seen from the foregoing chapters, the following very 
outstanding data regarding the conditions associated with the 
presence and absence of dental caries: First, individuals with a 
marked susceptibility to dental caries have at that time an in- 
creased susceptibility to rheumatic group affections, and this 
group tends in this condition to have a depressed ionic calcium 
of the blood; second, individuals without susceptibility to dental 
caries and with a susceptibility to periodontoclasia (pyorrhea 
alveolaris) tend not to be susceptible in this condition to rheu- 
matic group lesions and tend to have an ionic calcium of the 
blood, normal or above; third, this latter group does not tend to 
have dental caries. 

It seems, therefore, very probable that susceptibility to dental 
caries is linked very closely and directly with the calcium factor 
of the blood and saliva. To determine this, we have made a 
large number of both total and ionic calcium determinations of 
saliva and blood of individuals with and without dental caries. 
A careful clinical examination of these individuals reveals that 
the saliva in the mouths of the patients with the periodontoclasia 
(pyorrhea alveolaris) tends to be markedly on the alkaline side of 
neutrality, with an increase in alkalinity in the periodontoclasia 
pockets. It is a conspicuous fact that dental caries never occurs 
in periodontoclasia pockets at the time of the active process. 

358 



CHAP. XXIX ETIOLOGICAJ FACTORS IN DEN I \i ( \RIES 

Active absorption processes may resemble caries but they con 
stitute a different phenomenon.) It is a most remarkable fact 
that, in general, the efforts that have been made to produce arti- 
ficial caries have either been only partially successful or entirely 
negative, it seems apparent that some very fundamental ele- 
ments in the process have not been provided for. 

With this in mind I have chosen to attack this problem from a 
new angle. Since all proteins and colloids are now shown to act 
probably, stoichiometrically that is, by the purely chemical 
force of primary valency we may assume that with a change 
of the hydrogen-ion concentration from the alkaline to the acid 
side of the iso-electric point of that medium, we will have a change 
in the ion of that medium with which that substance will enter 
into chemical combination. We are quite familiar with the 
illustrations of the charged ions from a silver electrode, which is 
positively charged, disbursing from that electrode with their 
positive charges under the law, that like potentials repel, and un- 
like potentials attract. 

When a tooth is bathed in saliva with pH above the iso-electric 
point of that saliva, it can combine only with the anions, which 
are metals and bases; or, when of a pH below this iso-electric 
point, will combine only with acid ions. If, however, the entire 
tooth or the majority of its surface is bathed in saliva of a Ph 
above the iso-electric point and at some point on the tooth there 
is, because of mechanical conditions, a lower hydrogen-ion con- 
centration sufficient to be on the acid side of the iso-electric 
point, immediately two distinct changes have been established. 
In this latter condition there is a reversed polarity with the result 
that the tcoth surface will be positive, the liquid in this restricted 
acid zone negative, while the balance of the tooth will be negative 
to a zone which is positive : namely, the surrounding saliva. This 
establishes a closed circuit battery. As ions of calcium compound 
are dissolved by the acid, they are charged with the same sign as 
the tooth and therefore repelled from it ; and with increasing con- 
centration of that acidity there is an increasing repulsion of the 
calcium from the tooth, whereas the normal environment of the 
tooth should be alkaline and the tooth and the calcium should 
be of opposite charge, and the tooth would therefore attract the 
calcium ions and that would, by the process of crystallization, 
build into and upon the tooth structure, if that alkalinity became 
sufficiently strong to make the potential charge greater than the 



360 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

force required for the crystallization and ionization. 

We have, then, the visualization of dental caries. The normal 
saliva is slightly on the alkaline side of the iso-electric point of 
saliva. The normal tendency is for calcium ions to have an op- 
posite charge to that of the tooth structure and therefore will be 
attracted to it and the process of intensive calcification will go 
on by purely stoichiometrical processes, which must be recognized 
as slightly different from the metabolism, as we think of it, in cell 
function since there are no living cells present in this process. 

Starches lodge in interstices of the teeth in which they are pro- 
tected from the alkaline saliva in which, if not protected, they 
could not develop. Nor could the acid medium they generate 
remain acid if the normal saliva had free access to it to neutralize 
it. But proteins, such as the saliva, are amphoteric — that is, 
have the capacity of being either acid or alkaline — and this same 
saliva may be chemically very similar, except in relation to the 
compounds which will be built up and torn down by it, and from 
it. The lactic acid producing organisms, of which there are many, 
can in this environment produce a pH as low as 4 or even 3. This 
would make a marked difference of potential and completely 
reverse the forces between the tooth and the medium surround- 
ing it. The organisms are, however, directly protected from the 
surrounding medium by an organized membrane, the bacterial 
plaque, which is a leathery substance, a result of chemical com- 
bination between an excretion of the organisms and the proteins 
of the saliva. As fast as these acid ions come through this mem- 
brane, they combine with the proteins of the saliva, producing 
substances which are insoluble in the saliva. The following fac- 
tors are necessary for the maintaining of this condition. The 
alkali reserve of the saliva must be decreased, in general, to a 
point sufficient to make it possible for a still further lowering to 
be established and maintained at a point of bacterial protection 
of an acid producing bacterium of sufficient activity to change 
the local acidity of the saliva at the point in question well below 
the iso-electric point of that saliva. The organisms which do 
this must have a supply of starch or carbohydrate from which 
they produce the lactic acid for still further reducing the hydro- 
gen-ion concentration. 

In a normal condition of the mouth the factcr of safety is suf- 
ficiently on the alkaline side of the iso-electric pcint of saliva to 
maintain a constant potential between the ionic calcium of the 



CHAP \\i\ ETIOLOGICAL FACTORS IN DENTA1 ( VRIES 361 

saliva and of the tooth to keep calcium continually entering the 
tooth structure. Under certain conditions, such as fever, preg- 
nancy, etc., this normal environment of the mouth is changed. 
Since every substance, when placed in a liquid medium, tends to 
produce ions of its structure in that medium, there is always 
maintained a balance between the forces, expressed as valency 
between ions, and the forces of solution and crystallization. In 
pregnancy this normal balance is broken through a change of 
environmental fluids, blood, and saliva; calcium goes out of the 
tooth under this law of ionization. Slowly but definitely the 
teeth lose some of their substance as ionic calcium compounds. 
The factor of safety being reduced, it is much more easy for local 
zones of bacterial growth to create a condition just over the iso- 
electric border on the side of relative acidity, with the effect that 
in such teeth, and with such an environment of saliva, the decay 
takes place very much more rapidly than in an ordinary mouth 
where the normal factor of safety is in general maintained. We 
must remember that acidity and alkalinity are relative factors 
dependent upon the iso-electric point of that individual's saliva. 
In case, then, the individual has a high ionic calcium of the blood, 
he has a high capacity for maintaining the alkalinity of the saliva ; 
and this type of individual tends, as we have shown, to tear down 
alveolar bone about the tooth to maintain an extreme alkalinity, 
but in so doing produces an environment which accomplishes two 
things. It prevents dental caries by its large alkaline factor of 
safety and it tends to make the enamel of the tooth more dense 
than normal. This type of individual tends to have the glassy 
dentin on all surfaces of abrasion. 

Our studies have shown, as have also the studies of others, that 
practically all teeth before eruption are in a condition in which 
the enamel will stain very perceptibly with silver nitrate and 
other stains, for an appreciable distance into the enamel, and 
that after eruption the enamel surfaces of the tooth undergo a 
change in which there is apparent increase in the density of the 
surface enamel so that they stain much less readily, and in old 
age and in all adult life free from caries, the surface layer of 
enamel is but slightly penetrable by silver nitrate. This process 
of hypercalcification (as I have chosen to term it) is pretty largely 
completed by the twentieth year of life, after which, except in 
periods of disturbed saliva, there is little tendency to dental 
caries. 










-:-•..> raj 



b m 



a ■ ■ 



*^<" V « 


^^j 




HhHH^^t**. "' 


«'.. *.. *■" * 








* * 


' • ' ~"^ 




.t-- 




'■ r5^^B*^W(H8v^ 










Figure 163. The microscopic appearance of a section of a tooth with an arrested caries. Two mag- 
nifications. 

362 



CHAP. XXIX ETI0L0GICA1 FACTORS IN DENTA] CARIES 

We have, therefore, in the change of environment, as pro\ id< d 
by the change in the hydrogen-ion concentration of the saliva, 

its ISO-electric point, and its ionic calcium, factors which enter 
largely into the condition of immunity and susceptibility to 
dental caries. It is a quite frequently seen phenomenon that a 
mouth, in which caries has been active, has suddenly, ceased to 
be so, and vice versa. Among the factors which enter into life to 
bring about these changing states, are febrile disturbances, 
physical and nervous overload, and pregnancy. An illustration 
of the effect of the latter upon a tooth, is shown in Figure 163, 
which shows a cross section of the tooth with a deep caries ex- 
tending nearly to the pulp. It will be noted that a secondary 
dentin has been thrown down on the pulpal surface beneath the 
approaching caries; and this caries, which at one time was active 
and progressive, ceased to be so, and there is a strong demarcation 
in cross section between the zone of living dentin and the dead 
dentin of the caries. The period at which this happened, as de- 
termined by the patient's report of the condition of the tooth, 
corresponded with the period of pregnancy and lactation, and 
this was an individual with normally a high defense. In the 
higher magnification shown, the etching out of the dentinal tu- 
buli is very clearly disclosed ; and it is both interesting and signifi- 
cant that, in this case, the zone of limitation of the advancement 
of the bacteria into the dentinal tubuli is distinctly marked. The 
irritation of the toxic bacterial products undoubtedly sufficed to 
produce the reaction within the pulp, which caused the laying 
down of the secondary dentin. 

SUMMARY AND CONCLUSIONS. 

Dental caries is dependent upon the following factors: 

(a) A reduction in the hydrogen-ion concentra- 
tion of the normal environment of the tooth. 

(b) An acid producing bacterium. 

(c) A change in the chemical constituents of the 
pabulum bathing the tooth. 



CHAPTER XXX. 
THE NATURE OF SENSITIZATION REACTIONS. 

PROBLEM: Do dental injections produce sensitizations 
of an anaphylactic character? 

EXPERIMENTAL AND DISCUSSION. 

For several years, I have been seeing illustrations of systemic 
diseases, the chief characteristics of which were quite unlike those 
of ordinary bacterial invasion, and which seemed very definitely 
to be related to dental conditions. The following is the history of 
such a case previously reported by me. 

The patient, a man about forty, presented with the following 
history. For two years he had been affected with recurring head- 
aches followed by digestive tract disturbance (not preceded by it) 
and accompanied by lassitude ; which made it practically impos- 
sible for him to carry on his business. For the last six months 
prior to his coming, he had been practically compelled to abandon 
his business, and was in a state of mental discouragement and de- 
pression as a result of his physical disability. An examination of 
his mouth showed very extensive periodontoclasia, and, bacteri- 
ologically, very profuse fusiform and spirochete infection. At our 
first sitting we curetted one-fourth of the mouth. Within a few 
hours he suffered a violent attack of his characteristic headaches, 
followed before morning by acute digestive tract disturbances, 
with purging, cramping, and mucous stools. This attack lasted 
for a couple of days. After it subsided, he reported that he felt 
better than he had for some time, and was convinced that the 
reaction was related to his dental condition and its treatment. 
In about five days the other half of the upper arch was curetted, 
which operation was followed by a similar reaction though less 
severe. Similarly, at intervals of about five days, the lower arch 
was curetted, one-half at a time, during which time he was con- 
tinually improving. Soon after the gingival infection was obliter- 
ated, a couple of teeth, being considered too far advanced for 
treatment, were extracted. His health returned to normal and 
has remained so for ten years, except that on many occasions he 
has felt the beginning of the old symptoms returning, has pre- 

364 



( HAP \\\ l HI NAT! RE I F SENSITIZATION REA( I IONS 

sented promptly for treatment, and generally in proportion to 
Ins development toward the condition of sensitization, he re- 
sponded in the same manner to treatment, though with much 
less severe reaction. IK' became so familiar with his symptoms 
that on several occasions he telephoned during the day saying, 
"I feel one of my old attacks coming on. I low quickly may I 
have a treatment?" which would always be given at the earliesl 
possible moment, sometimes within an hour or two. The treat- 
ment was successful in aborting the attack in proportion to the 
earliness in the attack when the treatment was instituted. Many 
forms of treatment were tested, such as the injections of emetin 
and succinimid of mercury, subcutaneously, which had but slight 
effect. We will refer to the nature of these symptoms in later 
paragraphs. 

Another case with a similar sensitization complained because 
we did not do more of the curettage in gingival treatment at the 
first sitting; and when we advised her that she probably would 
have a reaction and to let us know regarding it by telephone the 
next day, she assured us that she would either telephone or come 
in. On the next day, she found herself feeling so miserable that 
she not only did not come to the office but did not even get up 
from her bed, even though the telephone w r as on a stand near the 
head of her bed. She said, "Well, what's the use of telephoning? 
He knew I would be sick anyway." She really did not have 
energy enough to reach the telephone, and report. Similarly, after 
her first acute reaction was over, she felt distinctly better. We 
have also reported previously, in the paper referred to, the cyclic 
nature of these sensitizations, some having a period of five or six 
weeks in the early stages, or even several months, with the perio- 
dicity shortening to two or three weeks, and finally even less. 

Occasionally, though not generally, we found that after the 
extraction of infected teeth without gingival infections, the pa- 
tients had very marked reactions which were more like toxic proc- 
esses than bacterial invasions. A careful study of a large number 
of these cases suggested that this toxic factor was in many in- 
stances very important, and seemingly more important than the 
bacterial invasion factor. W r e, accordingly, instituted a long 
series of experiments to determine the nature and qualities of the 
toxic substances in teeth, if such existed, and their effects on 
animals both directly and in connection with the bacterial strain 



366 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 
SENSITIZATION REACTIONS TO TOOTH TOXINS 



Group 


No. in 
Group 


Days 
Lived 


Loss 


Actual 


% 


% per day 


Organisms washed and 

suspended in NaCl 
Whole Culture Group I 
Whole Culture Group II 
Filtered Tooth Washings 
Unfiltered Tooth Washings 
Sensitized Rabbits 


8 

16 

55 

13 

8 

4 


7 
6 
7 
5 
12 
4 


203 
209 
226 
191 
221 
94 


18 
18 
20 
19 
22 
10 


2.6 
3.0 
2.9 
3.8 
1.8 
2.5 



Figure 164. 



found in these teeth. Figure 164 shows the results of these studies. 
It will be noted that in the group of animals inoculated with the 
washed organisms suspended in sodium chloride, the loss in weight 
per day was 2.6; and in the unwashed or whole culture, 3.0, the 
dosage being adjusted to approximately the same number of 
organisms: namely, the amount that would be in 1 cc. of a 24 
hour culture broth. A second and larger group of 55 rabbits 
receiving the whole culture, had a loss of 2.9. The average length 
of time, however, that the animals lived in these three groups was 
approximately the same: namely, 7 in the first, 6 in the second, 
and 7 in the third. When, however, animals were inoculated 
with filtered tooth washings, the average length of life was 5 days 
for 13 rabbits, with a loss per day of 3.8 per cent; and with the 
unfiltered washings, they died on an average of 12 days, with an 
average loss per day of 1.8 per cent. In another chapter I have 
discussed the probable reason for the greater toxicity of the fil- 
tered washing than the unfiltered, as judged from the length of 
time the animals lived. When, now, we compare with these 
figures the effect of injection of the whole culture into rabbits 
that had been previously sensitized by injecting, intravenously, 
a small quantity of the filtered washings, (not the total quanity, 
as above, from the tooth in question and from the chips of which 
the organisms were grown for this whole culture), this remarkable 
result came out, that the average length of life of 4 rabbits so 
treated, was 4 days after the injection of this culture (Note that 
this is less than the average length of life of rabbits in any of the 
preceding groups) and the percentage loss per day, per rabbit, was 
2.5. Two possible factors, at least, were possibly contributing, 
one a sensitization and the other an additive injury. The fact, 



CHAP. XXX l ill \ \n KM OF SENSITIZATION REA< riONS 36' 

however, that some rabbits not included in this group, died within 
a few minutes or hours after being injected with the culture where 
they had previously been sensitized by the use of the toxic sub- 
stance from that tooth, precludes, in those cases, the possibility 
of the explanation's being due toan additive factor, since they died 
from typical sensitization phenomena, such as scratching the nose, 
violent peristalsis of the intestines, labored breathing, etc. An- 
other argument against this being an additive factor is the fact, 
that when succeeding injections below the lethal dose of a given 
culture are used in the same animal, it tends to build up defense, 
which, with most cultures, can be brought to a state of very high 
toleration, permitting of massive doses without lethal effects. 

In the preceding chapters, 17 and 20, I have discussed the 
capacity of teeth for containing toxic and bacterial products, and 
have demonstrated that the quantity therein may be ample to 
produce very profound disturbances, both in animals and in 
humans. I have brought out the fact that approximately five per 
cent of even a well root-filled tooth is fluid, which may be culture 
media or toxic product; and also that when animals were inocu- 
lated with the bacteria-free soluble toxin derived from the infected 
tooth, they developed very definite and characteristic symptoms, 
and also that, in some instances, they were much more sensitive 
and susceptible to the organisms cultured from that tooth; that 
the toxic substance taken from teeth tended to disturb metab- 
olism and start a procession of changes which usually terminated 
in death, and usually with marked changes in the digestive 
tract, with great loss of weight. In another chapter, we will 
study the structural changes of tissues as a result of these proc- 
esses. It is, however, important to note here that, in some in- 
stances, an acute diarrhea was produced in from thirty minutes to 
two hours after the injection of this toxic substance, and animals 
not infrequently died having had blood-streaked mucous stools. 
It is, therefore, apparent that we are dealing with substances of 
profound toxicity. There are, however, many types of sensitiza- 
tion which differ from these expressions of toxicity. In one case, 
we are dealing with systemic poisoning from a violently acting 
toxin; in the other, with a state of exalted irritability of tissue, a 
true anaphylaxis or allergy. While this is not intended to be a 
treatise on immunology, it seems necessary for me to give a brief 
review of the conditions which obtain in true anaphylaxis. 

When proteins are injected parenterally into suitable animals, 



368 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

they may pass through the blood stream without any apparent 
effect. If, however, at a subsequent date, particularly from six to 
twenty-eight days after this first injection of protein, which may 
have been a very small dose, there is again injected into the circu- 
lation of that animal some of the same protein, it will produce an 
entirely different effect. In many instances there will be dis- 
turbed breathing, itching of the skin, itching of the nose, and if 
the animal is particularly sensitive it may die in a few minutes 
from spasms of the bronchioles, with continuation of cardiac 
function after the cessation of respiration, or the animal may 
entirely recover. The processes that have developed are some- 
what as follows : 

The first or sensitizing dose sets up in that animal the develop- 
ment of an active mechanism capable of splitting that protein, in 
order that it may be eliminated from the blood. The first or sen- 
sitizing dose may have floated in the blood stream largely for days 
before that mechanism had been sufficiently perfected to split it. 
With the consummation of that mechanism the animal was able 
to split large quantities of this protein in a short time; but since, 
according to Vaughn, all proteins split into a poisonous and non- 
poisonous part, the poisonous part being the same in all proteins, 
there is set free in the system a quantity of poison which, if not 
immediately eliminated, does harm by its presence. This con- 
stitutes the sense of illness from disease and the cause of pyrexia. 
Vaughn states that the amount of poison in a gram of cheese, 
when thus split, is sufficient to kill seven hundred guinea-pigs. 
The first or sensitizing dose may in some instances be only a 
minute fraction of a gram and yet be sufficient to prepare the body 
to react vigorously against a second dose. The introduced pro- 
tein is spoken of as the antigen and the substance which the body 
develops as the antibody. An illustration of the extreme delicacy 
of this mechanism is familiar to all in hay fever. The individual 
who suffers from hay fever is usually sensitized to the pollen of 
some weed, grain, or flower, and the amount that is necessary to 
bring on a reaction is so infinitely small, that it may drift invisi- 
bly in the air and doubtless can be less than a millionth part of a 
gram. In Part Two, under Other Tissues, we give illustrations of 
anaphylaxis to dental infections in addition to those given here. 

With these fundamentals of protein sensitization in mind, let us 
review the following case from practice: The patient presents 
with a history as follows: For some time he had been suffering 




369 



370 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

from recurring attacks which were increasing in severity and fre- 
quency, closely resembling hay fever but not related to any season 
or locality. Careful and exhaustive studies had been made by 
specialists in different cities to find the nature and cause of his 
sensitization, without avail. Figure 165 shows roentgenograms of 
his teeth which have evidently been infected for years, but have 
given him very little inconvenience or disturbance. Upon the 
extraction of the first tooth, he developed, within six hours, the 
most severe attack of his sensitization reaction he had ever had. 
Figure 166 shows his appearance which lasted for days. His eyes 
were bloodshot; tears would drip from his eyes; and the mucous 
would almost stream from his nostrils. His headache was ex- 
treme. The inflammation involved all mucous membranes of the 
mouth, nose, eyes, and throat, and extended around his eyes, nose, 
and mouth, approximately half an inch. The night of his first 
attack he did not sleep a moment, according to his report, and his 
distress was pathetic. The use of mild sprays, carrying adrenalin 
and cocain, greatly relieved his suffering. The tooth that was 
extracted was cultured, and the toxin washed from it injected into 
two rabbits. Both developed extreme inflammations. In one 
the eyes were bloodshot and tears running in forty minutes; and 
for two days profuse discharge was coming from its nostrils, shown 
in Figure 166. Note : This animal is not reacting from anaphyl- 
axis, not having been previously sensitized. It is apparent that 
we are dealing here with a substance which has profound tissue 
affinity, and which is not bacterial, though it may be a bacterial 
product, since the fluid injected into the rabbits had been passed 
through a Berkefeld filter and was bacteria-free. Subsequently, 
the balance of the infected teeth were removed, a few at a time, 
without serious reaction, and the patient's health very rapidly 
and splendidly improved, and for a year he has been without a 
single recurrence of his old and troublesome affection. Since the 
reaction in the rabbits was produced by the filtered washings of 
the tooth, we cannot interpret their disturbances as a tissue 
affinity quality of a particular bacterium injected. 

A striking illustration of an anaphylactic state or sensitization 
produced in a rabbit is as follows : Rabbit 184 was inoculated on 
Feburuary 18th with a salt solution washing of two crushed 
teeth, (biscuspids,) intravenously. Its weight at this time was 
855 grams. On the 23rd its weight had increased to 920 grams, 
and on March 1st to 1046 grams. On March 2 it was inoculated 





I 




Figure 166. A, a recurring acute inflammatory sensitization reaction produced 

IN A PATIENT BY HIS DENTAL INFECTION; B, A RABBIT WHICH DEVELOPED ACUTE LACRI- 
MATION AND RHINITIS IN FORTY MINUTES AFTER INOCULATION WITH WASHINGS FROM THIS 

PATIENT'S CRUSHED TEETH. 

371 



CHAP. XXX THE NATURE OF SENSITIZATION REACTIONS 373 

with the culture grown from these same teeth; weight 1075 grams. 
Within three hours after the inoculation of approximately 1 cc. of 
the whole culture, which is the bacterial suspension in the media 
in which they were grown, the rabbit died. The postmortem 
examination showed the liver to be slightly enlarged, stomach 
normal but very pale in color, lymph glands surrounding the 
stomach markedly enlarged, edematous, and resembling grapes, 
spleen enlarged, and lungs collapsed. The diagnosis of cause of 
death was anaphylaxis. 

The literature and teaching of the past have placed a particular 
emphasis on certain groups of symptoms as being characteristic 
of sensitization, expressing themselves chiefly in the skin, air 
passages, and bronchioles. We have, accordingly, been in the 
habit of looking for symptoms as the chief ones expressive of 
anaphylactic reactions. We are, however, coming to believe 
that many tissues respond with true anaphylactic reaction which 
we have not regarded as likely seats of this allergy. 

Inasmuch as individuals sensitized to foreign proteins have cer- 
tain definite reactions to that foreign protein, we have made ani- 
mal studies to determine whether the introduction of the toxic 
substances taken from the teeth would develop in animals a state 
of anaphylaxis which could be demonstrated by dermal and other 
reactions. We have found that the toxic substance taken from 
some teeth, when injected into rabbits, does produce in from six 
to twenty-eight days a true state of anaphylaxis, as evidenced by 
the fact that they showed definite dermal reaction to either the 
placing of the toxin on a scarification or the injection of a minute 
quantity of it in the superficial layers of the skin. We have found 
also that in some cases this toxic substance sensitizes the animal 
not only to this toxic substance which, though bacteria-free when 
injected, prepares that animal to respond to a washed suspension 
of the organisms grown from the tooth which produced that toxin, 
but also to the culture medium in which those organisms have 
grown. A rabbit inoculated with a bacterial suspension grown 
from the tooth from which the toxin was extracted to sensitize 
that rabbit, when the suspension was inoculated into this rabbit, 
died within two minutes showing the classical symptoms of shock, 
or true anaphylaxis. Studies of this problem on several hundred 
rabbits reveal that all infected teeth do not have this toxic sub- 
stance in the same quantity nor do they have the same qualities. 
Those familiar with the problem of sensitization reactions in 



'<»• 



374 DENTAL INFECTIONS, ORAL AND SYSTEMIC—RESEARCHES— VOL. I 

animals understand that the rabbit is not a favorable animal to 
use for this investigation, in that it is not highly sensitive to ana- 
phylactic reactions as compared with the guinea-pig. We have 
used both guinea-pigs and rabbits. Particularly because of our 
other observations with which we wanted to make comparisons, 
such as elective localization of the organisms involved, we decided 
to use the same type of animals for our sensitization tests. We 
have deemed that there would be some advantage in not using 
animals that are too sensitive to anaphylactic reaction. 

The recent literature has stressed the relationships between 
anaphylaxis and shock, and these in turn with reaction effects of 
animals inoculated with histamine. With this latter the animal 
dies from failure of respiration, usually in a few minutes after 
injection, during which time it exhibits a group of symptoms very 
similar to those exhibited by animals dying from anaphylaxis 
from the injection of a protein to which they have been previously 
sensitized. All such animals exhibit characteristic disturbances 
of the lungs and viscera, as marked engorgement of the capillaries 
and mesentery and visceral arterioles. 

Figure 167 shows the normal vascularization of the mesen- 
teries and intestines of a rabbit. Note the blanched white condi- 
tion of the mesentery and the constricted blood vessels of the in- 
testine. The specimens shown in Figure 168 are from a rabbit dying 
from a sensitization produced by crushing the tooth, injecting 
this into a rabbit, and later the rabbit was inoculated with the 
culture grown from this same tooth. This rabbit died in two 
minutes with the characteristic reactions exhibited in anaphyl- 
axis. In the inoculation of over fifteen hundred rabbits for various 
purposes, no rabbits have died quickly, following inoculation as 
this rabbit has done, except where previously sensitized by such a 
process as this inoculation with the washings of a crushed tooth. 
Note the engorgement of the blood vessels of the intestines and 
mesenteries. Figure 169 shows the same condition in the similar 
tissues of a rabbit inoculated with histamine. 

This condition is not comparable to the reaction produced in 
the rabbit injected with the material taken from the tooth of the 
patient referred to above shown in Figure 166, which symptoms 
developed about forty minutes after the first injection, since that 
rabbit was not sensitized by a previous injection. This reaction 
was probably a tissue irritation and in addition an elective locali- 
zation. In other words, the rabbit shown i n Figure 166 is not an 
illustration of allergy or anaphylaxis. 



CHAP. XXX rHE NATURE OF SENS1 flZAI ION REA< Mux- 














\^y 



Figure 167. Normal 

TKSTICLES OF A RABBIT. 



VASCULARIZATION OF MESENTERIES, INTESTINES, AND 



In studying the skin reactions of animals, we have found two 
distinct types: First, appearing in from a half minute to thirty 
minutes and subsiding in a few hours, characterized by a central 
wheal from a fourth of an inch to one inch in diameter, which is 
raised, edematous, and hard, and surrounded by an erythematous 
area from a half inch to an inch and a half in diameter, as shown 
in Figure 170. We have also found a secondary reaction developing 
in from six to eighteen hours, which may last for a few hours or 



376 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




Figure 168. The vascularization of mesenteries, intestines, and testicles 
of a rabbit sensitized with the washings of a crushed tooth. 

for several days, and in which the area originally occupied as the 
central whitish wheal is now deep pink and surrounded by a more 
or less deep pink area, often with an increase of temperature of the 
surface and the appearance of a scald or burn that is just short of 
the production of the water-blister. These vary in intensity. 
These are the characteristic reactions that make up the Schick 
test for the identification of diphtheria, as expressed in the first 
reaction, and the tuberculin test for tuberculosis as expressed in 
the second reaction. 

Having demonstrated the presence of this condition and re- 
action in animals, we have made tests upon many patients to 



CHAP. XXX rHE NATURI OF SENSITIZATION REA< I IONS 







* 




J 



Figure 169, The vascularization of the mesenteries and intestines of a rabbit 

INJECTED WITH HISTAMINE. 




Figure 170. Two mild and one strong positive reactions in a rabbit's ear t.iat ham 

BEEN SENSITIZED TO A DENTAL TOXIN. 

determine whether or not they would develop either or both of these 
reactions. Figure 171 shows the primary reactions of the patient 
shown in Figure 166, when tested with the extract of the toxin 
from his tooth, prepared by three different methods. Figure 171-B 
shows this same arm with its secondary reactions. The essential 



378 DENTAL INFECTIONS, ORAL AND SYSTEMIC RESEARCHES— VOL. I 

features about this patient's case are that he had recurring at- 
tacks, cyclic in nature, the periods of which had been shortening 
for years and which latterly had become weekly or biweekly. 
This readily eliminated the possibility of its being seasonal and 
related to pollens, etc. If it be a true allergy, the dermal test 
should give the typical Schick reaction, provided that it is possible 
to extract the toxic substance which is producing the antigen, or 
which is acting as the antigen. Many methods have been used for 
extracting the sensitizing substance, including those generally in 
use for selecting the antigen from pollens, foods, etc. We have 
here evidence both that the patient is suffering from a true allergy, 
the antigen of which is coming from his infected teeth ; and the 
antibody-antigen reaction takes place in the mucous membranes 
of the eyes, nose, and mouth. The fact that he had no recurrence 
for a year afterward, except a slight suggestion of an irritation at 
the time of the hay fever of August, is a strong indication that his 
primary disturbance was of this origin. It will also be noted that 
this patient had a strong secondary reaction from this original 
test and which reaction none of the controls of the six members of 
the staff developed, an additional evidence that we are in this case 
dealing with a specific reaction to a specific antigen. 

In many of these cases we have found the patients sensitized 
to the toxic substance as extracted from infected teeth of other 
individuals, and in other instances, evidences of a marked speci- 
ficity to the infection of their own teeth. In cases where the toxin 
was extracted from the patient's own tooth, the test, when posi- 
tive, developed more rapidly and usually more severely. We have 
also found a difference in the reaction effect from toxin taken 
from teeth of periodontoclasia conditions from those with chronic 
periapical involvements. The data are not sufficient for making 
deductions or generalizations. 

In addition to the regular or classical symptoms we are now 
coming to recognize other lesions as being directly related as true 
allergies. Conspicuous among these are skin disturbances, ex- 
pressing themselves as dermatoses which may be very persistent 
and painful. Such a one is shown in Case No. 1334, a professional 
pianist who became incapacitated by the presence on the palmar 
surfaces of his hands of a scaly dermatosis accompanied by 
marked stiffness of his fingers. His hands would crack to or near 
the point of bleeding. (See Figure 172 -A before treatment; and, 





Figure 171. Upper. Three positive primary dermal reactions on the arm of the patient 
shown in Figure 166. LOWER. One positive secondary reaction prom same patient. 



[chap. XXX — THE. natCre of sensitization reactions.] 

379 



CHAP. XXX mi: \ \Hkl-: OF SENS1 HZATION REA< I IONS 381 




I 







Figure 172. A scaly dermatosis, with marked stiffness of fingers. A, upper, before removal of 

DENTAL INFECTION; B. LOWER. AFTER. 



382 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES VOL. I 

172-B, after treatment. ) The condition did not respond to medica- 
tion. The extraction of an infected tooth, shown in Figure 173, 
completely eliminated his trouble, and at the same time a condi- 
tion of lassitude and mental languor. An extract of the toxic sub- 



Figure 173. The dental in- 
fection INVOLVED IN THE SKIN 

lesion of Figure 172. 




stance taken from his tooth was applied as a dermal test and in 
thirty minutes produced the enormous wheal shown in Figure 174. 
The secondary reaction in this case was negative, as shown in 
Figure B of the same figure. 

These studies have suggested that the toxic substance which is 
present in the patient's body, might possibly be found in the 
patient's blood, if a test could be developed which would be sensi- 
tive enough to record it, since, apparently, infinitely small quan- 
tities are adequate to produce very marked tissue reactions in 
sensitized tissues. 

Another type of skin reaction, typical of this group, showing 
dermal sensitization is shown in Figure 175. A shows a lesion on 
the patient's elbow which was distinctly defined, slightly raised, 
brownish in color, without erythema, with a tendency to scaling 
on the affected surface. B shows two positive primary dermal 
reactions to a toxin extracted from his tooth. The secondary 
reaction in this case was negative. After the removal of his den- 
tal infections and before they were completely removed, his skin 
disturbance entirely disappeared as shown in C. My interpreta- 
tion both of these primary and secondary reactions is given in 
Chapters 45 to 56 on Interpretation. 

Figure 176 shows the roentgenographic record of some of the 
teeth of this patient. It will be noted that there are very exten- 
sive areas of bone absorption, both at the gingival borders and at 
the root apices. The local dental pathology corresponds with his 
clinical history. He is a man of unusually high defense, and has 
carried this large amount of gingival and apical infection for a 



/ 






Figure 174. The dermal reactions of the patient in Figures 172 and 173. Lower, 
positive primary; upper, negative secondary. 

[chap. XXX — THE nature of sensitization reactions.] 

383 



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388 DENTAL INFECTIONS. ORAL AND SYSTEMIC RESEARCHES— VOL. I 

number of years. A constant passage into his system of the irri- 
tant protein compounds from these teeth, seems to have created 
a state of hypersusceptibility and reactivity. 

At this point I wish to discuss an important phase of the 
cases which, so far as we know, is entirely new. When we com- 
pare the type of systemic disturbance with the researches on the 
variations in chemical constituents of the blood, this important 
new fact has come out. In a group of individuals suffering from 
typical sensitization reactions, we found that the type of dental 
pathology, as expressed in the mouth, is that of extensive or 
marked rarefying osteitis, which I have interpreted as indicating 
an active reaction locally about the source of infection, and which 
active and vigorous reaction is a good sign and constitutes the 
quarantine station protecting the patient. But this extensive 
absorption of alveolar bone, as revealed in the roentgenograms, 
did not take place lately, but years previously; and in all prob- 
ability, as indicated from the history, for a long period of time 
these individuals did not have anaphylactic reactions from these 
processes. In studying the ionic calcium of the blood it was 
noted that these individuals have a high normal, usually above 
normal, whereas the individuals suffering from the typical rheu- 
matic group lesions generally had an ionic calcium of the blood, 
at the time they were suffering from their rheumatic group le- 
sions, which was below normal, frequently considerably below. 

I have found one type of rheumatism which appears to be 
present only in individuals having a pathologically high ionic 
calcium. Histopathologically, it is quite a different type of re- 
action from that of the arthritides. It is generally characterized 
by degenerative, rather than proliferative, processes, which some- 
times are revealed roentgenographically by the radiolucency of 
the bones. 

Since it is demonstrated that this quality of anaphylactic 
reaction to dental infection occurs only in individuals who have 
had a history of very high defense against streptococcal infections 
and rheumatic group lesions, we have in the histories of all of the 
patients, shown in this group, evidence of an overload of dental 
infection in an individual with a high capacity for reaction, which 
overload of dental infection was maintained for a long period of 
time. The effect has seemed to be that inasmuch as one of the 
first principles of defense is the capacity to reacting to a relatively 
small quantity of' the irritant, these individuals developed so sen- 



CHAP XXX rHE NATURE OF SENSITIZATION REACTIONS 

sitive a mechanism of reaction thai when the local barrier began 
to break down immediately about the infected teeth, those tissues 
which were most easily capable of developing an exalted reactiv- 
ity, disclosed the presence ol' this toxin which had laterally become 
able to pass into the system, and they have thereby suffered ;i 
more or less constant state of exalted reactivity in these very re- 
active dermal tissues. So far as I know this is the first time this 
evidence has been observed, suggesting a simple interpretation of 
the nature of the anaphylactic reaction in these individuals. I 
have discussed this further from this standpoint in the next 
chapter on Precancerous Skin Irritations. 

In order to study the capacity of toxic substances extracted 
from infected teeth for sensitizing rabbits to extracts made from 
the cultures grown fro n the same teeth, I have inoculated animals 
with these products with results shown in the chart in Figure 177. 
Rabbits 789 and 790 were controls ; and it will be noted that they 
did not show skin sensitizations to the extracts from any of these 
products; whereas, Rabbit 814 showed an anaphylactic reaction 
to a sodium hydrate extract from the culture grown from the teeth 
of another patient; and in Rabbits 846, 847, and 848, we find all 
three rabbits, which have previously been injected with the toxic 
extract taken from this individual's teeth, were all sensitized and 
gave anaphylactic reactions to the sodium chloride filtrate to the 
extract of the whole culture grown from the teeth of this same 
patient as shown in Rabbit 846; and Rabbit 847 showed a re- 
action to the sodium hydrate extract from the culture grown 
from the teeth of this patient, and in Rabbit 848 the same condi- 
tion. Whereas the tests for the extracts made by all the other 
methods were negative, these latter two w r ere positive in sixty 
minutes and lasted for two hours. 

Another group of rabbits was tested by using as our extract the 
toxic substance obtained from some recently extracted infected 
teeth from several different patients. These showed different 
reactions to extracts made by different methods. Whereas 
Rabbit 778 reacted to the extract of the whole culture, Rabbit 780 
reacted to the powder obtained from the dehydrated washings, 
Rabbit 781 to the whole culture and the powder obtained by 
dehydrating and washing, and Rabbit 779 to the powder and the 
whole culture. 



390 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

DERMAL SENSITIZATIONS DEVELOPED IN RABBITS 

A. Ear used as Test. 



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No gross pathology found. 



B. Abdomen used as Test. 



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Figure 177. 



CHAP W\ I III NATURE OF SENSITIZA1 ION RE M riONS 391 
SUMMARY AND CON( I I SIONS. 

In summarizing these studies of sensitization we desire to 
present the above data as a preliminary report, for much of the 
information is not ready for interpretation. Some important 
facts, however, should be noted. In the first cast' presented with 
acute inflammation of the nose, throat, lips, and eyes, the extract 
which was taken from the tooth and which produced such violent 
reactions in the patient in thirty seconds to two minutes, pro- 
duced practically no reactions in any one of six members of the 
staff treated similarly at the same time, which clearly indicated 
that we were dealing with a specific reaction. 
From these data we are led to conclude: 

1 1 ) That teeth contain substances other than bac- 
teria to which the individual may become sensi- 
tized, and which substances may, in addition, have 
strong toxic properties. 

i2> The evidence here presented suggests that 
dental infections are capable of producing in an in- 
dividual a state of anaphylactic sensitization, which 
condition may entirely and apparently permanently 
disappear with the removal of the dental infections. 
These disturbances may occur in dermal tissues, 
mucous membranes of the nose and throat, lac- 
rimal tissues, mucous membranes of the bron- 
chioles and air passages, as asthma, and the mucous 
membranes of the digestive tract and a number of 
other types of tissues. 



CHAPTER XXXI. 
PRECANCEROUS SKIN IRRITATIONS. 

PROBLEM: Are there relationships between precancerous 
skin irritations and dental injections? 

EXPERIMENTAL AND DISCUSSION. 

In the preceding chapter the researches disclosed that dental 
infections may produce in individuals very marked anaphylactic 
reactions in various tissues of the body. It was also revealed 
that there is a relationship between the dental infection, the ionic 
calcium of blood, and the patient's history of a quite complete 
absence of rheumatic group lesions, and that this condition de- 
veloped only in individuals having a normally high defense 
against streptococcal lesions. A frequent site of these lesions 
was shown to be the skin which is one of the first tissues to react 
to anaphylaxis. This has led us to a consideration of some of 
the types of skin lesions which have tended to recur and persist, 
and in time, occasionally, or in some types frequently, have taken 
on premalignant or definite malignant tissue types. 

Before proceeding with this discussion, I want to forestall mis- 
apprehensions and misrepresentations which are very likely to 
be unintentionally made. I am endeavoring to be very careful 
not to say that dental infections have been shown to be the cause 
of cancer. I am trying to illustrate that since cancerous growths 
develop in chronically irritated tissues, the data I am here pre- 
senting suggest only that dental infections may, in this indirect 
way, be contributary to these states of irritation. 

Figure 178 shows such a case. This patient had suffered for 
months from a lesion in the skin of her nose which had been diag- 
nosed as a skin cancer. The roentgenograms of the teeth of this 
case are shown in Figure 179. It will immediately be noted that 
this individual had extensive areas of absorption for a long period 
of time (for thirty- four years as evidenced by the history) and 
at fifty-two years of age she is developing this persistent lesion 
on the side of her nose. It has tended to fluctuate, varying in 
severity but never entirely disappearing, usually carrying a thick 
angry looking scab. We prepared a note for her, directing her to 

392 



CHAP.XXX1 PRE( VNCEROUS SKIN IKK'I I \ I H >\v 



393 




A B 

Figure 178. Skin i vnceh of the nose and its appearance three 

WEEKS 1 VTER AFTER REMOVAL OF DENTA1 INFECTIONS. SEE TEXT. 



a cancer specialist for its treatment with radium. Almost im- 
mediately following the obliteration of her dental infections the 
red border surrounding it disappeared and it showed evidence of 
rapid healing. B is a photograph of the lesion three weeks after 
the making of the photograph shown in A. Her nose cleared up 
so completely that, as shown in the picture, it was difficult to 
detect where the original lesion had been. The lesion remained 
healed for five months when it showed slight tendency to return, 
at which time she was taken to the cancer specialist who gave it 
two treatments with radium, since which there has been no re- 
currence. 

We shall not presume to interpret this history, but present the 
suggestion that if this patient was sensitized to her dental infec- 
tion in such a manner as were the individuals shown in the pre- 
ceding chapter, it is not impossible, nor even improbable, that 
the dental infection had direct relation, whether as a primary or 
as an additive factor, in the etiology of the lesion on her nose. If 
it may be that the state of abnormal cell proliferation is due to 
liberation of some toxic substance from the focus, set free in the 
system that has a high capacity for reaction to it, taking on a 
state of sensitization, it is not impossible that an additive factor 
may thereby be furnished, if not a primary causative factor, in 
the development of a neoplastic proliferation, in support of which 
suggestion I will present the following. 

When these individuals are sensitized, for this individual was 
suggested to be from her dermal reaction, they take on a state in 
which, when the extracted toxin is added to a slight scarification 



394 DENTAL INFECTIONS, ORAL AND SYSTEMIC RESEARCHES^VOL. I 




z 



z 

a 



of the forearm or introduced in solution into or just beneath the 
external layer of the skin, there occurs frequently, in a very 
few seconds, and practically always, in a few minutes, a vascular- 
ization with a very marked dilatation of the capillaries. When 
tubes carrying such a sensitizing antigen are placed beneath the 
skin of a rabbit, as in its ear, and removed in a few minutes, it is 






CHAP.XXX1 PRECANCEROUS SKIN IRRITATIONS 395 

found that there is a very rapid migration of leucocytes to the 
zone. Carrel] has shown thai leucocytes contain an activating 
substance capable of inducing cell defense and proliferation com- 
parable to the activation of embryo and tissue juice. This sug- 
gests as a possibility that dental infections may produce irrita- 
tions either in the epithelial tissues, as shown in these various 
skin reaction cases of the preceding chapter, or in mucous mem- 
branes, also shown in the preceding chapter; and it", as is fre- 
quently the case with these lesions, they remain located in a given 
spot for a long period of time, it may be possible that a hypersen- 
sitiveness, a part of which constitutes a marshalling of the leuco- 
cytes, may be one of the important steps in the development of 
neoplasms. Possibly related to this will be found the develop- 
ment of abdominal cysts, many of which we show produced in 
rabbits in Chapter 62 of Part Two. In the Chapter on Lesions 
of the Digestive Tract in Part Two (Chapter 65) we recite a 
number cf cases of lesions of the alimentary canal, chiefly the 
stomach, which seem directly related to dental infections, inas- 
much as chronic lesions, as stomach ulcer which had been recur- 
ring for years, have entirely disappeared and have remained ab- 
sent for a number of years following the removal of the dental 
infections, and the teeth from which cases, when cultured, pro- 
duced in rabbits, as shown in those chapters, many instances of 
stomach ulcer and perforations of the stomach and intestines. 
We will discuss this phase of this problem further in our general 
interpretations. 

I have said, "if she was sensitized. " In order to determine 
this I made extractions from her extracted teeth and tested both 
of these and also an extract from the organises grown from her 
teeth in culture media and found her to react positively to the 
dermal test and maximum positive in twenty-five minutes, which 
disappeared in three hours. The same antigen used on control 
individuals was negative. It is my interpretation, therefore, that 
she was, as a matter of fact, in a state of allergic sensitization to 
the toxic substance being developed in her dental infection. 

I am quite familiar with the fact that there is divergence of 
opinion as to whether there is any hereditary tendency associated 
with cancer; and, indeed, the evidence is far from conclusive that 
there is such. If, as I have suggested, sensitization processes 
may tend to contribute to precancerous irritations, it would be 
entirely possible to explain the association of these irritations in 



396 DENTAL INFECTIONS, ORAL AND SYSTEMIC-RESEARCHES— VOL. I 

families without requiring as a premise that the cancerous condi- 
tion, per se, is transmissible. To illustrate: Individuals do not 
transmit to their posterity, periodontoclasia, or so-called pyor- 
rhea alveolaris. However, it is a condition which is found to in- 
volve all the members of some families and be absent in all the 
members of other families. The factor that seems to be trans- 
missible in this case is an exalted or highly efficient capacity for 
reaction against the presence of an irritant; and, since all the 
members of the family have been blessed with this high defense 
in common, and since all individuals tend to have irritating de- 
posits about the teeth, and irritating food packs about improper- 
ly spaced teeth, or those with destroyed contact points, the 
irritants to which to react are practically universal. The removal 
of the irritants and prevention of their recurrence will usually be 
all that will be necessary in these individuals to prevent the 
development of a local disturbance spoken of as periodontoclasia, 
or pyorrhea alveolaris. Similarly, since only individuals with a 
normally high defense reacting against a persisting toxic antigen, 
seem to develop this state of sensitization, it would not be strange 
if different individuals in the same family developed such similar 
reactions to similar irritants. This may be the explanation for the 
phenomena which are exhibited in the chart shown in Chapter 65 
in which it will be seen that the patient has stomach irritation, 
sluggish liver, and acute digestive disturbance, from which dis- 
turbance one of his brothers is also suffering, and also both his 
father and mother. It is also important that his father's father 
and one of his father's brothers died of cancer of the stomach at 
sixty and sixty-three years of age respectively, and his mother's 
mother of a chronic stomach disturbance, not identified, at the 
age of sixty-four. The history of this family shows a marked ten- 
dency to periodontoclasia in each the patient, two of his brothers, 
and his father. This, as we have shown, is a disturbance which 
tends to develop in individuals with normally high capacity for 
reaction. They, therefore, would also have a high capacity for 
reaction to other sources of irritation, not necessarily of dental 
origin, though readily from that source, which might express 
themselves as sensitizations. If, then, there be an inheritance of a 
tendency to low defense of stomach tissue, this sensitization proc- 
ess could readily attack that tissue and in this definite but in- 
direct way, either precancerous or cancerous conditions may pos- 
sibly be associated and related when they occur in different mem- 
bers of the same family, as here shown. 



CHAP.XXX1 PRECANCEROUS SKIN IRRITATIONS 39' 

SI MMAKY AND CONCL1 SIONS. 

Since more indi\ iduals lose their lives from cancer oi the stom 
ach than from cancer of any other type of tissue, and since dental 
infections are shown in the chapter referred to, to be directly 
related to so main- rases of acute and chronic - digestive tract dis- 
turbance, we should be exceedingly careful that dental Infections 
are not permitted to become a predisposing factor, for it lias been 
abundantly shown that cancer of the stomach tends largely to 
develop in the scars of healed ulcers. Until we have more knowl- 
edge as to the extent of anaphylactic reactions in the main - le- 
sions produced and aggravated by dental infections, we cannot 
with safety undertake to interpret the full role which dental In- 
fections play in acute, chronic, or malignant processes. The evi- 
dence, however, is sufficient to suggest extreme caution in matters 
of prophylaxis. 

The evidence available suggests: 

a i That dental infections may produce localized 

anaphylactic reactions, as irritations of the skin and 

mucous membranes. 

(b) That these sensitizations may develop into 

precancerous conditions. 



CHAPTER XXXII. 

RESEARCHES ON DENTAL INFECTIONS AND 
CARBOHYDRATE METABOLISM. 

PROBLEM: What, if any, is the relationship between 
dental infections and carbohydrate metabolism? 

EXPERIMENTAL AND DISCUSSION. 

By relating the lesions, which occur in other parts of the body 
in association with acute and chronic gingival infections, we have 
an opportunity for securing direct information and also sugges- 
tions as to what may be the causative factors producing both the 
oral and the systemic disturbances. I have shown in Figure 
131 Chapter 20 (showing relation of blood chemistry studies 
to systemic involvements like diabetes, etc.) and also in 
other places that certain groups of disturbances tend to be asso- 
ciated, as, for example, a pathologically high ionic calcium of the 
blood, low alkali reserve, low respiratory coefficient, extensive 
gingival involvement with alveolar absorption, high blood sugar 
(hyperglycemia), sugar in urine (glucosuria), tend to be associ- 
ated, and that this group tends not to have deforming arthritis 
or acute rheumatic group lesions; whereas the group, with the 
other extreme of divergents from normal, does tend to have sus- 
ceptibility to the rheumatic group lesions. It is therefore sug- 
gested that the associated factors must be operating in these two 
conditions. 

I have, accordingly, undertaken a series of researches to estab- 
lish, if possible, some of the mechanisms herein involved. Since 
the presence or absence of sugar in the urine is dependent in dia- 
betes mellitus upon a disturbed carbohydrate metabolism, it is 
very probable that the mechanism controlling that process is 
directly related to the various modifications in the two distinct 
types of lesions. It has been known for some time that the sur- 
gical removal of the pancreas always tends to produce typical 
diabetes with death in the animal, in a few weeks. The rise in the 
sugar in the blood is constant as it is also in the urine. This has 
led many investigators to a search for the specific hormones, 

398 



CHAP. XXXII DENTAJ INFECTIONS & CARBOHYDRATE METABOLISM 399 

which, it was interpreted, must be developed by the pancreas, 
controlling the metabolism of the carbohydrates. Very erratic 
but occasionally definite i\ idence was developed which indicated 
that the process was a complicated one. Recently Banting, 1 Best, 
Collip, and Macleod haw succeeded by a special technic in 
isolating a substance from the pancreas, which when injected 
into normal animals, definitely and rapidly lowers the blood 
sugar, and which, when administered to depancreatized animals, 
immediately reduces their blood sugar to, or below normal in 
accordance with the dosage. They have demonstrated that this 
substance is a product of the islets of Langerhans. When ex- 
tracts are made of a whole adult pancreas, a quantity of the 
specific substance, to which they have given the name insulin, is 
secured in varying amounts, as judged by the effects upon ani- 
mals when making injections with this material. 

It seems very probable from experimental data that the differ- 
ences in these reactions are not due entirely to differences in 
amounts of insulin, but in large part to differences in the amount 
of some other substance which probably is extracted from the 
same pancreas, and which excites an influence in the opposite 
direction. In other words, when carbohydrates are taken into 
the body they are at first formed into sugars. In a normal indi- 
vidual this sugar is stored in the liver as glycogen and a liberal 
quantity is carried in the blood to the various tissues of the body 
where it is oxidized in the process of work and is the principal 
body fuel. In diabetes the body has lost the capacity for burn- 
ing this fuel and it accordingly accumulates in the blood. In that 
state the body has lost the capacity for storing it as glycogen in 
the liver. Nature also stores away the excess by adding addition- 
al carbon, depositing it in the tissues as fat. This fat may be 
called upon in the absence of fuel, and by oxidizing its carbon 
atoms from the molecules in pairs, reduces it from fat to glycogen, 
glycogen to sugar, sugar to butyric acid, and finally carbon diox- 
ide and water. In diabetes the body cannot completely burn up 
these sugar compounds, does not reduce them lower than a butyr- 
ic acid, which latter then develops into the acetone bodies which, 
when they accumulate in the system, become very toxic. In 
Chapter 64 on Arthritis we record many rabbits in which we have 
produced typical various types of rheumatism by the injection of 
cultures from dental sources, usually from patients suffering from 
rheumatic lesions. 

On the theory that the pancreas furnishes two opposing hor- 

1 T See bibliography 



400 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

mones which produce an equilibrium in accordance with their 
relative amounts, one of which is insulin, I have wondered if it 
might not be true that another hormone, not as yet isolated, 
might be one of the substances which is directly attacked and 
destroyed by the types of infection which produce acute chronic 
rheumatism; and if in other patients the dental infection or its 
toxins injures the functions of the islands of Langerhans, thereby 
diminishing the supply of insulin. It has been shown that, where- 
as the pancreas of mammals contains two distinct types of secret- 
ing cells, one of which constitutes the islets of Langerhans, some 
of the mammalia have these two tissues separated into different 
organs, as, for example, in some of the fishes, particularly the 
scallop. 

I have shown in Chapter 20 that cultures taken from dental 
infections are capable of greatly changing the percentage of sugar 
in the blood of animals and also the development of a glycosuria, 
which condition recovered in a few weeks, but which was repro- 
duced in the same animal by reinoculation of a culture from the 
same patient, which patient was suffering from diabetes. We 
have, accordingly, repeated this experiment, having in mind 
especially the structural changes in the pancreatic tissues and in 
carbohydrate metabolism. We have also undertaken to modify 
these effects by injecting the animals with the opposing enzyme 
or hormone, assuming that two exist, which are in apposition in 
the affects. The results of these studies will be published later. 
These researches are in progress and have opened up an entirely 
new approach to a very important problem, since in a large num- 
ber of our patients there has been a marked improvement in the 
glycosuria and the hyperglycemia following the removal of dental 
infections. 

SUMMARY AND CONCLUSIONS. 

Dental infections may produce marked changes 
in carbohydrate metabolism and probably struc- 
tural and degenerative changes in the islets of Lan- 
gerhans of the pancreas, with the production of 
hyperglycemia and glycosuria. 



CHAPTER XXXIII. 
MARASMUS. 

PROBLEM: Why do people with rheumatic group lesions 
tend to he underweight? 

EXPERIMENTAL AND DISCUSSION. 

Few, if any, of the symptoms of rheumatic group affections are 
so constantly found as that of marasmus. This condition of pro- 
gressive wasting and emaciation may range from 10 to 25 per 
cent in ordinary cases, to 35 to 40 per cent in extreme cases. 

The patient shown in Chapter 64 has increased in weight from 
72 to 111 pounds, an increase of more than 50 per cent of her 
weight at the time her dental infections were removed, her nor- 
mal prior to her affection being about 130 pounds. She had, 
accordingly, lost nearly half of her original weight. A culture 
was taken from one of her infected teeth and inoculated into the 
rabbit shown in Figure 180. In four days' time this rabbit reduced 
in weight from 1381 to 1105 grams, a loss of 276 grams, approxi- 
mately 20 per cent. The amount of culture injected was 1 cc. of 
a 24 hour growth. (Sixteen drops, not quite a teacupful.) B 
shows the marked tissue atrophy about the eyeball which has 
shrunken so as nearly to fill the orbit. 

It is not, however, necessary that even this quantity of organ- 
isms be injected, for even the washings of a crushed tooth will 
produce this extreme emaciation. A patient presented whose 
principal lesion was his great emaciation. He stated that he felt 
fairly well, nothing particularly wrong except that he could not 
regain his weight, which he was progressively losing. He had 
several dental infections, largely the result of former pockets of 
active periodontoclasia, now harboring a mixed infection. One 
of his teeth was crushed, washed, and centrifuged. The clear 
solution was inoculated into the rabbit shown in Figure 181. This 
rabbit lost in weight from 1430 grams to 843 grams, a total of 41 
per cent in 16 days. We have estimated by counting the number 
of organisms and weighing a quantity of them, that the actual 
organisms inoculated into this rabbit would be approximately one 
millionth of a gram. 

401 



402 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 





Figure 180. Marked tissue atrophy produced by injection of a dental culture, 
twenty per cent in four days. no cleft between eyeball and socket. 



To test this matter still further, we have passed the washings 
from crushed teeth through a Berkefeld filter and have injected 
the bacteria-free solutions into rabbits and have produced typical 
marasmus. We have shown elsewhere, in a discussion of the 
effects of the toxic substances contained in infected teeth upon 
experimental animals, that there is a marked loss in weight follow- 
ing their injection. For example, in thirteen rabbits inoculated, 
intravenously, with filtered washings of teeth, where the death 
was spontaneous, the average length of life was 5 days, the aver- 
age loss per rabbit was 191 grams, and the average percentage 
loss in 5 days was 19, or almost 4 per cent per rabbit per day. 

In chapters 59 to 112 there are shown many patients with 
various types of rheumatic group lesions: muscles and joints, 



t. II MV \\\ll! M \R \s\ll S 



103 




FIGURE 181. Typical marasmus in rabbit inoculated with clear washings from crushed 

TOOTH OF PATIENT. RABBIT LOST 41 PER CENT IN SIXTEEN DAYS. 

heart, nervous system, digestive tract, etc. Accompanying 
these practical cases are shown animals inoculated in various 
ways with various cultures of dental origin and with toxic sub- 
stances extracted from teeth, and the percentage of their loss of 
weight at the time they were chloroformed, or died. 

In a group of 667 successive rabbit inoculations, some with 
cultures and some with filtrates of cultures, and many with 
filtered washings from crushed teeth, therefore bacteria-free, 
33 1 3 per cent, or 220, lost in weight from 10 to 30 per cent in a 
few days or weeks immediately following the injections ; and 8.7 per 
cent lost from 30 to 50 per cent in weight; 13.6 per cent gained 
from 10 to 30 per cent, and 3.6 per cent gained from 30 to 50 per 
cent. It will be seen immediately that, in this group of rabbits 
selected serially, irrespective of the type of experiment, nature of 
culture, or method of inoculation, there is a very much larger per- 
centage of rabbits having a loss, than a gain. In other words, 42 
per cent of the animals lost more than 10 per cent in weight in a 
few days or weeks under which they were in observation, extend- 
ing from that to 50 per cent; whereas only 17 per cent gained 



404 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 
PER CENT LOSS OR GAIN IN WEIGHT AFTER INOCULATION OF 667 RABBITS 



Loss 


Gain 


10-30% 


30-50% 


10-30% 


30-50% 


33 3 


8 7 


13.6 


3.6 



Figure 182. 

more than 10 per cent. (See Figure 182.) 

When teeth are planted beneath the skins of rabbits, they often 
show a loss of weight within 24 hours; and in 100 consecutive 
plantings for various types of experiments, the loss of weight per 
rabbit per day amounted to 18 grams, which was 1.4 per cent. 
In chapter 17, we refer to a strain growing in a patient's teeth 
six of which teeth were tested on sixty rabbits by planting one 
of them beneath the skin, which in every instance killed the ani- 
mals in from two to ten days, with an average loss of weight of 26 
grams per day per rabbit, or 15 per cent per rabbit and 2 per cent 
per day per rabbit, an average total of 205 grams per rabbit. In 
Chapter 18, we have illustrated two rabbits, full brothers, 
kept on the same diet, one of which gained continuously and the 
other began immediately to lose in weight, after being injected 
with the washings from a crushed tcoth. 

In this connection it is of interest and important to note that, 
invariably as the ionic calcium of the blood is reduced by the pres- 
ence of the implanted tooth, the animals lose in weight. This is 
clearly shown in the chart in Figure 134, Chapter 20, in which 
a series of rabbits is shown to demonstrate the changes which take 
place in the calcium and thrombin of the blood in the presence of 
dental infection. In these the ionic calcium was very seriously 
depressed, and, as shown in Chapter 20, the evidence is very 
strong that this is a fundamental part of the process of bacterial 
overwhelming. It is also of interest to note, however, that the 
loss in weight is not exactly proportional to the loss in ionic 
calcium. 

The data, that are rapidly accumulating, strongly suggest, if 
they do not indicate, that infected teeth contain, in many in- 
stances, a toxic substance or substances capable of producing 
very many grave disturbances in metabolism, only one of which 
is the universal expression as marasmus. Since it is so common a 



CH \r XXXIll m \k \^mi S !•).. 

symptom of chronic dental infections, that patients having them 
are underweight and that they tend so frequently to gain in 
weight after the removal of their dental infect ions, together with 
the fact that whether we inject the filtered washings from the 
teeth or plant an infected tooth beneath the skins of rabbits, this 
effect generally quite rapidly obtains, we are, therefore, led to the 
presumption that these toxic substances are directly related to 
that symptom. 

SUMMARY AND CONCLUSIONS. 

(1) A study of our clinical records shows that a large percent- 
age of the patients suffering from rheumatic group lesions are 
from 10 to 30 per cent under weight, and that they tend to return 
to, or nearly to, their normal within a few weeks or months follow- 
ing the removal of their dental focal infections. 

i '1 ) When the same tooth which, when removed, produces such 
a change in the patient that he or she returns to his or her normal 
weight, is placed under the skin of a rabbit, it nearly always loses 
in weight, not infrequently 20 per cent in a few days. 

(3) When cultures grown from infected teeth are inoculated 
into rabbits, whether intravenously, subcutaneously, or intra- 
peritoneally, they tend to lose in weight though usually not so 
rapidly as when an infected tooth is placed beneath the rabbit's 
skin. 

(4) Filtered washings from infected teeth frequently cause 
very marked reduction in weight. 

We are, therefore, led to conclude: 

That dental infections, when they affect the 
patient systemically, frequently, if not generally, 
produce a depression of that individual's weight; 
and that marasmus, whether mild or severe, may be 
considered one of the diagnostic symptoms in study- 
ing the relation of dental infections to general 
health. 



CHAPTER XXXIV 
PREGNANCY COMPLICATIONS. 

PROBLEM: Do dental injections have a bearing on 
pregnancy complications? 

EXPERIMENTAL AND DISCUSSION. 

We have seen in Chapter 21 that one of the conspicuous over- 
loads, which contributes to susceptibility to rheumatic group 
lesions, is pregnancy; and having noted that so many of our pa- 
tients either presented with the development of these lesions dur- 
ing pregnancy and lactation, or with a history dating to that 
period, we were led to study to see whether or not dental focal 
infections may have an injurious effect upon that state. 

It has long been known that the administration of toxic sub- 
stances to pregnant animals has tended to injure the fetal forms 
often before the parent was seriously affected. This has been the 
basis of a procedure for producing a miscarriage by the use of such 
chemicals as the lead compounds. In our experiments we have 
found that when infection was introduced into pregnant rabbits, 
that infection produced more profound effects than when intro- 
duced into non-pregnant rabbits, and that this injury expressed 
itself in fetal forms before it did in the mother. Is it not probable 
then, that dental infections may have somewhat of the same 
effect upon human expectant mothers? This is a fact of very 
great importance in all the campaigns which have to do with the 
better care of expectant mothers and with the prenatal care of in- 
fants, and urges strongly that a part of all government co-opera- 
tion shall include the placing of the expectant mother's oral cav- 
ity in a condition free from focal infections, both for her own safe- 
ty and for the safety of her offspring. 

This is doubly true for the following reason : In pregnancy the 
demand for calcium is greatly increased, both for the general 
metabolic processes and for the new fetal form. It has also been 
shown in the preceding chapters that the presence of the dental 
infection furnishes a toxic substance which tends to combine 
directly with the ionic calcium of the blood, and besides produces 

406 



CHAP \\\i\ PREGNANCY COMPLK VTIONS ID', 




Figure 183. Dead fetal forms following injection of lcc. of dental culture. 

a toxic factor definitely reducing the available ionic calcium. 
In practically every instance where a tooth is planted beneath 
the skin of a rabbit, as we have shown, the ionic calcium of the 
blood is reduced. If, then, the expectant mother is to be de- 
prived of her available ionic calcium by having its effectiveness 
destroyed in the circulation, by being attached to a toxic factor, 
supplied by the dental infection in addition to the increased de- 
mand for that ionic calcium, we have two important contributing 



408 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

factors to a general lowering of defense, to make the third factor 
more serious and dangerous: namely, the direct injury of the 
foreign toxin produced by the dental infection upon the fetus. 
It is not an uncommon clinical experience to have premature 
labor pains develop with the onset of a dental abscess; and while 
it is not possible, in a given case, to say what the relative impor- 
tance of different contributing factors has been, it is not improba- 
ble that many miscarriages or prenatal injuries, many of which 
latter are permanent, may have their origin directly in the obscure 
and unsuspected dental infections. 

We, accordingly, injected cultures from dental origin into 
pregnant rabbits similarly as in our other studies. Figure 183 
shows a dissection of such a rabbit, in which five nearly developed 
fetal forms are dead and undergoing decomposition from the in- 
jection into the ear vein of 1 cc. of a 24 hour growth of a culture 
from a tooth. 

As a further means of study of this problem, we have planted 
pieces of infected teeth beneath the skin of pregnant rats in order 
that we might, if possible, observe the effect on both the mother 
and the offspring. The period of gestation in rats being three 
weeks, makes a very short experimental period, and it is difficult 
to determine the progress of the period of gestation by the appear- 
ance of the animals. There has been evidence of the premature 
birth of the offspring within a couple of days after the planting 
of the piece of infected tooth. 

SUMMARY AND CONCLUSIONS. 

We would, therefore, summarize these studies as follows: 

(1) These researches have shown that, in animals, 
infections from dental origin may have a very far- 
reaching effect on both the expectant mother and 
her fetus, which latter may be prematurely expelled 
or may be rendered lifeless. 

(2) Inasmuch as a large number of our serious 
cases of rheumatism, heart, and kidney involve- 
ments, have their origin at the time of pregnancy in 
humans, in which cases our clinical histories show 
that there have been present extensive dental focal 
infections, it is suggested as important, if not im- 
perative, that expectant mothers shall be free from 
dental focal infections, both for their own safety 
and efficiency and for the continued vitality of the 
fetus. 



CHAPTER XXXY. 

SPIROCHETE, AMEBA, AND OTHER 
NON-STREPTOCOCCAL INFECTIONS. 

PROBLEM: Do other organisms than streptococci enter 
the human system through daita! infections? 

EXPERIMENTAL AND DISCUSSION. 

The conclusion that has been reached in nearly all the recent 
reports on dental infections, bears out the evidence in the pre- 
ceding chapter, to the effect that, in general, dental infections may 
be considered as streptococcal or diplococcal infections. Our 
studies are revealing that while dental infections are practically 
always a part, and usually the all important part of the involved 
microorganisms, there are present with the streptococci, frequent- 
ly, other types of microorganisms which have a very serious effect 
on the host. These may include either protozoa or bacteria or 
both. We would discuss two of the protozoa infections first. 

In Figure 184 we have a large abscess on the neck which had 
resisted treatment for many weeks. A bacterial examination of 
its contents, shown in B, disclosed a large number of amebae. 
The history of the case revealed that a lower left first molar had 
abscessed with a fistula developing below the mandible, which 
later developed into a chronic abscess which persisted after the 
extraction of the tooth. C shows the mandible where the tooth 
was extracted. The use of succinimid of mercury, a good ame- 
bacide and disinfectant, as a wash and pack, produced the imme- 
diate healing of the abscess. 

We do not know to what extent spirochete forms from the 
mouth enter the human body. We are coming to believe that 
they do so much more often than has been realized. 

Figure 185 shows a rabbit's knee which has developed a huge 
tumor-like mass which, when opened, proved to be almost pure 
culture of spirochetes. A shows a large abscess in the thigh of the 
rabbit, from which a nearly pure culture of spirochetes and fusi- 
form was obtained, as shown in the smear in Figure B. The 
rabbit was inoculated intraperitoneally with the washings from 
a periodontoclasia! tooth of a patient who had been suffering from 

409 



410 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




Figure 184. Abscess on neck shown in A; ameba infection shown in B; origin from infected 

TOOTH SOCKET SHOWN IN C. 

an unusual type of neuritis, which was completely relieved by the 
extraction of the involved tooth. The lesion in this rabbit's thigh 
contained a culture, apparently, presumably like the culture 
which we had studied in the pocket beside the tooth before the 
extraction of the tooth. 

The direct influence of the spirochete infections upon the health 
of the individual may be both severe and rapid. Such a case is 
shown in Figure 186. This man had lost eighteen pounds in weight 



CHAP.XXX\ SPIROCHETE AND AMEBA INFECTIONS 111 




Figure 185. Spirochetal abscess 
produced in rabbit in a; b. culture 

OF SAME. 



Figure 186. Culture of spiro- 
chetes FROM TRENCH MOUTH, WHICH 
CAUSED PATIENT TO LOSE EIGHTEEN 
POUNDS IN THREE WEEKS. WITH LOCAL 
TREATMENT HE GAINED TEN POUNDS IN 
TWO WEEKS. 



4^ 



•-• 







■% • 



/«•%*■ 



'• v. 



s - 









412 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 







c& 









Figure 187. Ameba infection deep in the gingival tissue. 

in three weeks' time, and a most thorough medical examination 
could find no other cause. As an experiment, as well as a wise 
procedure, in his case because of the extreme painfulness of his 
gums, the first treatment was by means of packing the selected 
germicides between the teeth, with the remarkable result that he 
gained ten pounds in two weeks' time. 

Amebse may penetrate deeply into the soft tissues surrounding 
peridental involvements, and since amebse are nearly always 
present in pockets of periodontoclasia, it is not improbable that 
they may, at times, penetrate far into the tissues. Figure 187 
shows a large ameba deep in the gingival tissue in the neighbor- 
hood of a tooth with periodontoclasia. 

The infections may also penetrate deeply into the bone adjoin- 
ing a periodontoclasia! infection. Figure 188 shows such a case. 
The organisms are seen in the haversian canal of the alveolar 
bone adjoining the pocket of periodontoclasia. 

It now seems probable that one of the most important portals 
of entry for tubercular infection is through the cavities of dental 
caries of the teeth. From the dental caries they penetrate the 
exposed and infected pulp chamber, and from this gateway pro- 
ceed through the lymphatics to the deep and cervical lymph 




Figure 188. Organisms in an haversian canal, adjoining a periodontoclasia 

POCKET. 

glands of the neck. Careful observers in dental practice are con- 
stantly seeing the phenomenon of enlarged cervical glands, that 
have been persisting for periods of time, disappear with the re- 
moval of infected teeth. Particularly is this true with under- 
nourished children and their carious deciduous teeth. 

Another important phase of this problem is the role of dental 
caries and the teeth, in the matter of the furnishing of a nidus of 
infection, which come to be carriers. Particularly is this true of 
such diseases as scarlet fever and diphtheria. A first requisite 
for the disinfection of carriers of this type involves a complete 
eradication of dental infection and dental caries. 

But there is another type of infection which is very important 
and has to do with those involvements, which express themselves 
through long periods of the individual's life, as recurrences of a 
one time active process. A typical illustration of this is the follow- 
ing. A patient who had suffered for years from malaria went to 
a mountain climate to escape the possibility of the mosquito in- 
fection ; but notwithstanding that she had gone to a malaria free 

413 



414 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

district, she had frequent and definite recurrences of her malaria 
infection. She returned to Cleveland in midwinter, and in the 
process of my making her safe from her dental infections by the 
elimination of foci, after the extraction of her first tooth, she 
developed a violent and typical attack of malaria fever which was 
positively diagnosed by finding the Plasmodium in her blood. 
There seems no doubt but that the stirring up of this nidus set 
free again into her system this organism to produce its cycle. A 
most remarkable part of her history has been that, whereas these 
recurrences of malaria had been frequent prior to the removal of 
her dental infections, she has not had a recurrence in the five 
years since the removal of them. 

It is not yet clearly established whether lethargic encephalitis 
is produced by an organism of the diplococcus streptococcus 
group, or by a filterable virus. However, there have been many 
investigations reported which have tended to establish that it is 
due to the former. In Part Two on Degenerative and Defi- 
ciency Diseases, Their Relation to Dental Infections, I discuss in 
detail a case of lethargic encephalitis in which it seemed very 
probable that we were dealing with a type of infection in the 
tooth, which was directly related to that clinical syndrome, where 
the tooth was taken from a patient suffering from that disease. 
In this connection I will state that one of these teeth from this 
patient placed beneath the skin of thirty different rabbits, pro- 
duced death in from a day and a half to six days, with one very 
large rabbit living ten days, and the culture from which tooth, 
when injected subdurally, produced symptoms strongly sugges- 
tive, if not typical of that disturbance. It is also significant that 
three other teeth taken from this same patient produced similar 
effects. 

The seriousness of these spirochete infections, when they be- 
come acute, is common to all practitioners who have had an op- 
portunity for large experience and are generally referred to as 
Vincent's angina, trench mouth, etc. They may, or may not, 
show many fusiform. Frequently they are practically pure 
strains of spirochetes. We will discuss these in their different 
types and classifications in Volume Three on Diagnosis, Prognosis, 
and Treatment. 

SUMMARY AND CONCLUSIONS. 

(1) Our experience with these and other cases suggests to us 
the great need for very careful study to determine whether or not, 



CHAP.XXX\ SPIROCHETE VND AMEBA INFECTIONS H5 

particularly in cases of extensive periodontoclasia, there is an 
invasion of the organisms of those infective processes, and 
whether the sensitization reactions discussed in Chapter 30, 
are not directly produced, in many cases, by toxic substances 
generated by these other types of organisms. 

(2) The evidence at hand strongly suggests that infected teeth 
are the harbingers of both contagious and infectious organisms 
which may either attack the host on recurring occasions, or may 
be transferred by the host who may be non-susceptible and 
simply a carrier, to susceptible individuals. 

I 3 1 Dental prophylaxis becomes imperative both for the safety 
of the individual and for the community in which he lives. 

While the streptococcus seems universally to be 
present in dental infections in practically all cases 
of systemic involvement, in addition to this variety 
the evidence seems to establish that each staphyl- 
ococci and spirochetes may pass from infected 
teeth to other tissues and proliferate in localized 
areas; and, similarly, that when certain mixed 
strains are injected into experimental animals, 
localized spirochete infections may develop in their 
tissues. Systemic involvements from spirochete 
infections and their localization in experimental 
animals are, however, relatively rare. 



CHAPTER XXXVI. 
NUTRITION AND RESISTANCE TO INFECTION. 

PROBLEM: Does faulty nutrition, through a deficiency 
diet, decrease the defense against dental infections? 

EXPERIMENTAL AND DISCUSSION. 

Few of the overloads so effectually destroy the defense for in- 
fection and to such a degree, as does disturbed nutrition. It has 
been the universal history of the world that wars and famines 
have been followed by devastating infections. The recent newer 
knowledge of the nature of foods and their effects upon the de- 
veloping structures has enormously widened our knowledge of 
nutritional disorders. The epoch-making work of McCarrison 
in India, the Melanbys in England, McCollum, Funk, Mendel, 
Hess, and many others in America, has rapidly established the 
role of deficiency diets in the long list of physical affections which 
are more or less common in all lands ; and various types of lesions 
are shown to be very clearly dependent upon the absence of 
sufficient quantities of accessory food factors, generally spoken 
of as vitamins A, B, C, and D. McCarrison, particularly, has 
shown that many of the same diseases can be produced either by 
deficiency diets or by inoculation with certain infections. 

In our extensive studies of the reactions on animals inoculated 
with different strains of dental infections, we have repeatedly 
produced symptoms and lesions which resemble in a marked 
degree those produced by deficiency diets. This research was 
established to assist in determining the effect of diet in destroy- 
ing the normal defense of animals and the extent to which the de- 
velopment of infection processes has entered into the clinical 
pictures of nutritional disturbance, to produce the lesions that 
are found. Figure 189 shows three views of two rats, same age, 
one kept on normal diet, and the other on a diet deficient in 
vitamin B. It is shown here partially paralyzed from polyneuri- 
tis, which characterizes the deficiency of this vitamin. It would 
certainly be expected that animals with nervous systems under- 
mined by this deficiency of feeding would be more sensitive to 
infection introduced into the animals' bodies. Figure 190 shows 

416 



CHAP. XXXVI NUTRITION VND RESISTANCE fO INFECTION 117 



Figure 189. Two 

RATS SAME AGE, ONE ON 
NORMAL DIET AND T11K 
OTHER DEFICIENT IN 

Vitamin b. 




Figure 190. The 
rats on the deficiency 
diet have also less 
resistance for infec- 
TION. 




418 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

two rats, same age, one on deficiency diet, and the other on normal 
diet, both of which were inoculated with the same quantity of a 
strain of dental infection and in which a dose one-third of the 
tested lethal dose for a normal rat was used. 

The newer knowledge of the specific lesions produced by 
the absence of vitamins A and B has revealed that certain 
changes in the elements of the blood are in evidence before the 
physical disturbances appear. Cramer, Drew, and Mottram 18 
have shown a progressive decrease in the number of blood 
platelets following the withholding of vitamin A, resulting 
in a marked thrombopenia which, they state, is the only 
constant lesion in deficiency of this vitamin, just as lymphopenia 
is characteristic of deficiency of water-soluble B. They have 
also shown that the defense to infection is largely in propor- 
tion to the number of platelets, that, when they are reduced 
below a certain critical number, the animals become an 
easy prey to infective conditions which develop spontaneously, 
and which may give rise to secondary anemias, but which disap- 
pear, if the condition has not gone too far, on the addition to the 
diet of vitamin A. McCollum has further divided vitamin A, as 
understood previously, by limiting its classification to the specific 
substance, the absence of which produces xerophthalmia. He has 
characterized as vitamin D, the fat-soluble factor, the absence of 
which produces the lesions classified as rickets. 

We have inoculated rats with given amounts of culture grown 
from dental infections to determine, if possible, whether in that 
animal the absence of the vitamins would make them more sus- 
ceptible to this infection. These results have tended to disclose 
a very high resistance on the part of the rat for streptococcal in- 
fections. We have, however, noted in our inoculations of rabbits 
that in many instances there was a marked decrease in the plate- 
lets and in the thrombin as the result of the streptococcal inocula- 
tions, which effects in a degree are as extreme in some instances 
as the withholding of the specific vitamins. 

Vitamin B has been shown by Cramer to be directly related to 
the production of lymphopenia. Similarly, we have found 
strains which produced a very marked lymphopenia in animals, 
whereas other strains produce a very marked lymphocytosis. 
These are illustrated in the blood counts shown in the chapter on 
hematological changes in the blood produced by dental infections. 

An important phase of nutrition is involved in the typograph- 

1 "See bibliography. 



CHAP \\\\ I NUTRITION AND RESISTANCE TO INFECTION 419 

ical climate and isolation of various communities. I shall no1 
enter into a discussion of this problem of nutrition in its relation 
to Localized community conditions. This has been done exten 
sively by such writers as McCollum, McCarrison, etc. I will, 
however, report the result of a special study that I made among 
the mountaineers of North Carolina. In these studies, in which 
I went from home to home on the mountains and also in the val- 
leys, and made tabulations, I found abundant evidence that de- 
ficient nutrition was increasing the susceptibility to the rheu- 
matic group lesions. The diet of the mountaineers at that time 
(Feburary and March, 1919) consisted largely of fat pork, coffee, 
and the separated grits of the white corn, with a more than liberal 
use of tobacco, chiefly as snuff, which is painted around the teeth 
and consists of the powdered stems and leaves. This was far 
from being a balanced diet. Many of the individuals went for 
months without milk in their diet, and green foods and vege- 
tables were practically unknown out of season. These individ- 
uals showed, in many ways, distinct symptoms of calcium starva- 
tion. They were underweight, nervously irritable, and aged 
young, being frequently more decrepid at fifty to sixty than they 
should be at seventy to eighty. The most striking feature, how- 
ever, was the very marked prevalence of rheumatic group lesions, 
and in many homes I found bedridden sufferers with endocardi- 
tis, acute rheumatism, recurring, chronic arthritis, and many 
cases of digestive and nervous system disturbances. A more care- 
ful study of these individuals revealed a very unusual prevalence 
of dental caries, with striking illustrations of large numbers of 
broken down teeth, and hence with putrescent pulps and apical 
involvements, and yet, these frequently existed without fistula? 
or evidence of a normal defense and a reaction. They were not 
maintaining local zones of quarantine about these infected teeth 
or they could not have been in this quiescent condition. 

In order to throw r some additional light on the problem as to 
whether or not dental infections are more injurious in individuals 
on deficiency diets, I have undertaken to reproduce the conditions 
in animals for study. Different groups of rabbits and rats have 
been placed in a condition of deficiency in nutrition and then sub- 
jected to inoculations and implantations of infected teeth, to de- 
termine whether or not those with an unbalanced diet are more 
susceptible to the infections than the normals. The evidence to 
date, while, in general, corroborating this viewpoint, does not 



420 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

justify, however, the conclusion that the lowered defense can be 
charged in large measure to deficiency diet. In many instances 
the animals with deficiency diet showed remarkable power of 
defense against infection, though not quite equal to the normals. 
The results, in general, have been a disappointment in that they 
have not thrown as large a responsibility on the diet as we had 
expected. These studies are being continued and will be reported 
in extended detail later. 

The researches on this problem have been in progress approxi- 
mately a year and the data are being accumulated, which should 
throw dependable light on this important problem. Rats have 
not proved to be a suitable animal in which to determine varia- 
tions in streptococcal defense. 

SUMMARY AND CONCLUSIONS. 

The data at hand suggest : 

(1) That the effects of variations in the diet do 
not express themselves quickly in specific defense. 

(2) That variations in diet by the limitation of 
various vitamines produce effects which, in general, 
are similar to those of overload. 

(3) Deficiency diets, particularly disturbances 
resulting in a calcium hunger, tend directly to 
lower the defense to dental infections. 



CHAPTER XXXVII. 

THE RELATION OF THE GLANDS OF INTERNAL 
SECRETION TO DENTAL INFECTIONS 

WD DEVELOPMENTAL PROCESSES. 

PROBLEM: To what extent are the glands of internal 
secretion related to dental injections and to dental develop- 
mental processes? 

EXPERIMENTAL AND DISCUSSION. 

Probably no department of modern medicine has had a more 
rapidly developing literature than that of the glands of internal 
secretion. It is also true that a great deal that has been written 
has been based upon insufficient experimental evidence, being 
largely surmises as to the probable role of these various glands. 
There can be no doubt, however, of the important part which 
these glands play in all the vital processes, including calcification, 
metabolism, and immunity. I will not undertake to give an his- 
torical review of the literature in its relation to dental problems, 
as it would be much too voluminous for insertion here. (Its 
bibliography alone would cover at least one hundred pages.) 

I have directed these researches chiefly along the following 
lines: 

(1) The Correction of Disturbances and Disfunctions of the 
Glands of Internal Secretion of the Patients by the Removal of 
Their Dental Infections. 

( 2 ) The Production of Disturbances in the Glands of Internal 
Secretion of Animals by the Injection into Their Circulation of 
Cultures Taken from Teeth of Involved Patients. 

(3) The Modification of the Patients' Systemic Involvements 
from Dental Infections by the Administration of Extracts of 
These Glands. 

(4) The Improvement of the Functioning of the Glands of 
Internal Secretion by the Mechanical Stimulation Induced by 
the Movement of the Bones of the Face and Base of the Skull. 

We will discuss these under these four heads. 

12] 



422 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

1. THE CORRECTION OF DISTURBANCES AND DISFUNC- 
TIONS OF THE GLANDS OF INTERNAL SECRETION OF 
THE PATIENTS BY THE REMOVAL OF THEIR DENTAL 
INFECTIONS. 

It is difficult to state which of these glands is most frequently 
involved. Some are very frequently involved, particularly the 
thyroid and ovaries. In this great belt lying along the Great 
Lakes, there is exceedingly little iodin available in the soil and 
water, and, as a result, thyroid involvements of the various types 
are very common. It has, accordingly, become necessary to pro- 
vide iodin for the girls of all this district to make up for this de- 
ficency. 

Individuals with a defective thyroid due to lack of iodin, readily 
have that slight disfunction very greatly disturbed and aggra- 
vated by dental infection; and the dental infection is distinctly 
less disturbing to this gland, in the presence of this ample iodin 
in the food. For example, thyroid involvements from dental 
infections apparently are very much less frequent among peoples 
living along the oceans where the spray is drifted inland by the 
winds, than in this Great Lake belt. 

It is now understood that girls are very much more liable to 
have thyroid involvements than boys, so much so, that the latter 
are practically free from them unless it be a condition carried for- 
ward from the time of a prenatal insufficiency of the mother. 
Girls and women tend to have the thyroid involvements develop 
during the periods of physical stress, particularly during puberty 
and pregnancy. At these times it is very important that they 
should have an additional supply of iodin if this is not supplied in 
sufficient quantity in the food. A few grains given every six 
months will be sufficient to retain the normal functioning of the 
thyroid. 

To test out this important discovery, Marine and Kimball 
got permission to administer iodin twice a year to the girls of the 
public schools of the city of Akron, only those being accepted who 
furnished from their parents or guardians a written request for 
this treatment. Kimball 1 '' in his report entitled "The Prevention 
of Simple Goiter in Man," published in the American Journal 
of Medical Sciences, May, 1922, No. 5, summarizes the results as 
follows : 

There were 2305 girl pupils included in the tabulation of those 
not taking treatment and 2190 in the tabulation of those taking 
treatment. All were examined every six months and very care- 

19 See bibliography. 



CHAP. XXXVII DENTA1 INFECTIONS & INTERNAL SECRETIONS 123 

Cul records maintained. They divided their findings into three 
groups: First, those girls who had normal thyroids. Of thi 
there were 906 in the group taking treatment and 910 in the group 
not taking treatment. In the group taking treatment only 2 or 
0.2 of one per cent developed goiter; whereas in the group not 
taking treatment 347 of the 910 developed definite enlargement 
of the thyroid, or 27.6 per cent. 

Of those with a slightly enlarged thyroid, there were 477 in the 
group taking treatment, of which only 3 were recorded as having 
the goiter increased; whereas, in those not taking the treatment, 
there were 127, or 13.3 per cent where the goiter was increased. 
Similarly, of those with slightly enlarged thyroids, 659 of those 
taking treatment were recorded as having a decrease in the size 
of the goiter, whereas in those not taking treatment only 134, or 
13.9 per cent, showed decrease. 

In the group with moderately enlarged thyroids, of those taking 
treatment there were 29, or 20.3 per cent, showing no change ; and 
of those not taking the treatment, 57, or 64 per cent. Of those 
taking treatment none were recorded as having an increase in the 
size of the thyroid, where it had been recorded as moderately en- 
larged to begin with, while in those not taking treatment 21 of 
this classification showed enlargements, or 23.6 per cent. But 
even more striking is the evidence of therapeutic effect; for in 
this group with moderately enlarged thyroids of those taking 
treatment 114, or 79.7 per cent, showed a decrease. There is, 
therefore, strong evidence that the administration of the iodin 
had both a very marked prophylactic and therapeutic effect. 

Since the publication of this practical test developed by Marine 
and Lenhart in their intensive researches, the procedure has been 
carried cut in a great many countries as well as many districts of 
this country, and practically always with the same most gratify- 
ing results. With regard to the possible ill effects Kimball re- 
ports that, in all the cases taking the prescribed two grains of 
sodium iodide twice yearly, there was not a single evidence of 
exophthalmic goiter nor any evidence of a nervous irritability 
simulating it; and in all the cases only 11 of iodide rash, 6 of which 
were so mild as not even to require treatment. Less than one- 
half of one per cent showed any lesion or evidence of disturbance 
from the treatment. The importance of this cannot be overesti- 
mated since in many districts, such as the glacial areas of Switzer- 
land, Alaska, and British Columbia, a very large percentage of the 
humans and animals suffer from endemic goiter, and both are 
equally easily controlled, results being practically complete; and 



424 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

goiter is now considered one of the easiest of the known diseases 
to prevent. 

The result of this practical test of the value of new facts 
brought out by laboratory experimentation has been that the 
children in many inland communities in America and all children 
in Switzerland are compelled by law to be given the iodin at 
regular periods. If space permitted, it would be of interest to 
refer to other phases of the role of iodin in thyroid functioning 
and general metabolism. Two others will be sufficient. 

Animals are often involved as are humans. In a district of 
British Columbia where the iodin is particularly scarce in the soil 
and therefore in the plants and foods, it was found impossible to 
raise hogs because the young had little or no hair, had rough scrof- 
ulous skin, and failed to develop properly. The administration 
of a few grains of iodin to the pregnant sows, completely corrected 
the condition, so that now the raising of hogs in that district is 
carried on with as great ease and perfection as in normal commu- 
nities. The humans in this district were also seriously affected. 

Similarly, the fish in a hatchery of a neighboring state were 
dying off at such a rapid rate, that it seemed necessary to abandon 
the entire enterprise. At the suggestion of Dr. Marine who found 
on examination that these fish were suffering from goiters, 
they were given iodin in their food. This completely cured 
the malady. 

It is a very frequent experience to find acute thyroid involve- 
ments subside rapidly and often apparently completely with re- 
moval of dental infections. In Chapter 60 I have discussed in de- 
tail such a case. It is of particular interest first because the sys- 
temic symptoms cleared up very completely and the local thyroid 
enlargement reduced approximately to normal. Two years later 
with the development of an apical involvement of another tooth, 
the symptoms returned similarly, and if possible, more severely 
than at first, since there was a very considerable heart involve- 
ment, as tachycardia; and after the removal of this infected tooth 
the symptoms and the activity of the thyroid both disappeared. 
This condition of disfunction of the thyroid is so frequently met 
in our clinical work, that we look upon it as one of the very com- 
mon systemic expressions of dental infections. 

In the above chapter I refer to several cases with a discussion 
of the clinical phases, which illustrate clearly, without repetition 
here, that the removal of the dental infections in a large number 



CHAP.XXXVI1 DENTA] INFECTIONS & INTERNA! SECRETIONS 125 

of these cases completely relieves the acute disturbance, and the 
thyroids return to an approximately normal functioning, and 
otherwise very grave symptoms disappear. In thai chapter on 
Endocrines I also discuss the thymus and parathyroids. 

In further study of the improvement in functioning of glands 
of interna] secretion by removal of dental infection, I will discuss 
the effects of dental infections on ovaries and testicles. A causa- 
tive factor frequently associated with infections of these glands 
is an infective process which, because of the nature of the tissues 
involved, induces individuals suffering from such disturbances, to 
suffer in silence, notwithstanding their knowledge that there has 
been no opportunity for such an infection. In the chapter on 
Primary and Secondary Sex Organs I recite the details of a num- 
ber of cases where the evidence seemed very strong that the den- 
tal infections were the primary factor in involvement of these 
tissues. A brief review of some of these is as follows : 

A uterine discharge thought to be malignant in origin, which 
had persisted for six months and was growing progressively worse, 
entirely disappeared and has not returned for two years by the 
removal of dental infections, illustrated in a figure cf Chapter 62. 
A young woman, typical of many, suffering from a very severe 
suppression at the time of her periods, accompanied by marked 
mental disturbance, was completely relieved by the removal of 
dental infections. The condition, however, returned, and the 
removal of further dental infection completely corrected the 
trouble without return for a year and a half. A man with a pain- 
ful swelling of the testicles had the condition greatly relieved by 
the removal of dental infections. All of these cases are further 
discussed in succeeding paragraphs under the heading of the 
Production of the Disturbances in Animals by the Inoculation 
of Dental Infections from Involved Patients. 

While it has been known for some time that the pancreas plays 
a very important role in the metabolism of carbohydrates, the 
proof that the Islets of Langerhans furnished an internal secretion 
capable of correcting this disturbance, has not been available 
until the epical work of Banting, Best, Macleod, etc., through 
the isolation of insulin. When this substance is injected into 
normal animals, there is an immediate reduction of the blood 
sugar; and, similarly, when injected into animals from which the 
pancreas has been removed and which have thereby been induced 
to develop typical diabetes, the blood sugar is reduced in accord- 



426 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

ance with the dose of insulin injected. While it has been known 
that the pancreas plays this important role in the development of 
diabetes, it is not known what factors have been most active in 
causing this disturbance of the pancreas. 

In the course of these researches on The Relation of Dental 
Infections to Systemic Disturbances, many important new facts 
have been developed through the study of the chemical changes 
in the blood. Among these the changes in the blood sugar, due 
to the removal of dental infections, has been a very important 
one. A group of these cases is shown in Figure 131 of Chapter 20. 

A first effect of the disturbance of dental infections in cases of 
hyperglycemia is an aggravation of disturbance regardless of the 
method of conducting the surgery. These patients are poor risks 
for surgical operations, whether in the mouth or elsewhere. In 
another chapter I speak of the serious effect on these patients of 
the use of adrenalin. Since adrenalin is capable of producing in 
individuals or in animals an increase in blood sugar, or a lowering 
of the rate of metabolizing of carbohydrates, its injection with the 
anaesthetic, as is common practice with novocain to produce a 
more prolonged anaesthesia, frequently causes a very sharp rise 
in blood sugar in patients already suffering from a mild hyper- 
glycemia, and an alarming rise in patients with a severe sugar re- 
tention. It is, of course, obvious that in these patients the use of 
adrenalin must either be entirely dispensed with or reduced to a 
minimum. 

In ordinary dental practice diabetics are frequently presenting 
for service, who do not themselves suspect such a condition; and 
except he be trained in the methods of diagnosis, the dentist will 
rarely suspect the condition unless the patient has informed him. 
In our clinic where we make very frequent chemical analyses of 
the blood as part of our research, we find a large number of pa- 
tients with a mild or even severe diabetes mellitus who have no 
suspicion of the condition. Nor is an analysis sufficient for estab- 
lishing the presence of a diabetes mellitus, since there may be 
either an abnormal condition of the kidney, which allows sugar to 
pass from the urine into the blood even though the blood sugar 
is not up to the threshold of danger, or the sugar may be above 
the threshold in the blood, and not be present as a glycosuria. We 
do not consider that the reduction in blood sugar is of itself suffi- 
cient evidence to justify the conclusion, that the pancreas has 
been injured by the presence of dental infections, even though 



CHAP.XXXVI1 DENTA] INFECTIONS & INTERNAL SECRETIONS 127 

carbohydrate metabolism is definitely improved by the removal 
of dental infections. We would, accordingly, wish to consider 
the data in this paragraph in connection with that in the nexl sec- 
tion on the effects on animals. 

11. THE PRODUCTIONOF DISTURBANCES IN THEGLANDS 
OF INTERNAL SECRETION OF ANIMALS BY THE INJECTION 
INTO THEIR CIRCULATION OF CULTURES TAKEN FROM 
TEETH OF INVOLVED PATIENTS. 

It is very significant that in the inoculation of over 1500 rabbits 
with cultures from dental sources taken from patients suffering 
from various disturbances, it is exceedingly rare that the glands 
of internal secretion are directly invaded by organisms, unless the 
patient from whom the dental infection was taken was suffering 
from an active process. This does not mean that all animals in- 
oculated become so infected ; nor does it mean that this becomes 
of necessity a competent method for diagnosing whether or not 
the patient has such an involvement. In the chapter on Elective 
Localization of Organisms, I have showed that the quality of elec- 
tive localization is directly related to the culture medium fur- 
nished by the patient, and that a patient, with a diseased organ 
tends to furnish a modified culture medium, which in many in- 
stances seems to develop in the organism an elective localization 
for that tissue. We are not able to determine the completeness of 
the vicious cycle: namely, the role of the organ, furnishing to an 
individual with a disturbed general defense, a toxin and bacterium 
which attacks the involved tissue already injured by some 
ether cause, which diseased tissue furnishes some substance to the 
blood stream which develops or seems to induce in the organisms 
an affinity for that particular tissue. That this quality is tran- 
sient in the organisms we have showed by the fact that, when they 
are grown on artificial media for a short time they tend, usually, 
to lose this elective localization quality; but that it is specific to a 
degree in the organism during the immediate period following its 
transfer from the dental infection of the patient suffering from 
that lesion, to an animal without a lesion in the similar tissue, 
where it tends to develop disturbances in normal tissue of the 
type of that which is diseased in, or invaded by, infection from 
the dental infection of the patient. 

To save repetition of illustrations we do not present here many 
of the reproductions of these lesions in animals, of which a large 
number of cases are shown in the chapters on Primary and Sec- 
ondary Sex Organs and Endocrine System. Briefly these results 



428 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

show as follows : In the case shown in Figure 148, Chapter 22, four 
female rabbits were inoculated with the culture taken from the 
teeth of a girl suffering from acute ovarian involvement, and all 
four developed infection of the ovaries and tubes, or 100 per cent; 
whereas, in the total number of fifteen hundred rabbits inoculated, 
of which approximately half are females, this involvement has 
not been recorded in one per cent of the females. In the case 
referred to under the previous heading with purulent uterine dis- 
charge one of the rabbits inoculated developed an acute infection 
of the ovaries, tubes, and uterus. In the case shown, illustrating 
the patient suffering from pain and swelling of the testicles, three 
rabbits were inoculated with cultures from three different teeth. 
All three developed, as shown in illustration of same in Part 
Two, acute infection of the testicles; whereas, in approximately 
750 male animals inoculated with cultures taken from dental 
sources, not one per cent has shown involvement of these tissues. 

A typical illustration is shown in a figure of Chapter 62 in 
which case the patient had suffered from an ovarian cyst which 
was removed eight months previously and was approximately 
the size of a goose egg. Five female rabbits were inoculated with 
the culture from her extracted tooth and two developed cysts of 
the ovaries. Two of these are shown in Figure 191. One has three 
small cysts on each ovary. The rabbit was posted too soon to 
permit them to grow very large. Large ones produced in rabbits 
are shown in the chapter on Primary and Secondary Sex Organs. 

In the previous section of this chapter we have referred to the 
role of dental infections in relation to the pancreas, and diabetes 
as seen in the clinical study of these cases. We have tried experi- 
mentally to produce typical diabetes by the inoculation into rab- 
bits of cultures from the teeth of patients suffering from acute 
diabetes. The blood sugar of this patient was 130 mgs. per 100 cc. 
After the removal of her dental infections, she had a very sharp 
reaction which put her to bed for a few days. The culture grown 
from her tooth increased the blood sugar of the rabbit from 97 to 
149 with a single injection of the strain. A reinoculation of the 
rabbit with this strain again produced a rise in the blood sugar. 
Figure 192 shows the normal histology of the pancreas of a rabbit. 
Figure 193 shows the pathological histology of the pancreas of a 
rabbit in which an artificial diabetes has been produced. A 
pathological pancreas has a decreased number of functioning 
Islets of Langerhans, which is a very difficult condition to 
reveal histologically. 




Figure 191. Two rabbits which developed ovarian cysts. Patient furnishing culture had recently 

BEEN OPERATED FOR SAME. 



429 










Figure 192. (A) Normal rabbit pancreas. 
Figure 193. (B) Pathological rabbit pancreas. 
430 



CHAP.XXXVI1 DENTA1 INFECTIONS & INTERNAL SECRETIONS 131 

The only interpretation we are able to make of these 
phenomena is that dental infections tend under certain eon 
ditions to involve the glands oi internal secretions in the animals 
inoculated when these cultures are taken from patients suffering 
from acute involvements of these tissues. 

111. Till'; MODIFICATION OF Till-: PATIENTS' SYSTEMIC 
INVOLVEMENTS PRODUCED BY DENTAL INFECTIONS BY 
Fill-: ADMINISTRATION OF EXTRACTS OF THESE GLANDS. 

One of our most difficult problems has been to ascertain the 
role of the glands of internal secretion in the presence or absence 
of a defense against dental infections. Relatively little is known 
as to what constitutes the chief elements in the mechanisms of 
defense. Some elements, however, seem pretty definitely estab- 
lished or at least strongly suggested. Since patients with a good 
defense have, as a group, a high ionic calcium of the blood in con- 
trast with a relatively lower ionic calcium of the blood in patients 
with a low or broken defense, we seem justified in concluding that 
in some way this element, whatever the factors are which it may 
represent, is indicative of the nature of the defensive mechanism 
of the patient. In the preceding chapters I have brought out the 
following important facts: 

With the elimination of dental infections there tends to be a 
marked rise in the ionic calcium of the blood, when it is depressed, 
with a reduction of the pathologically combined calcium of the 
blood, if we are correct in our interpretation of our data. In some 
cases, in spite of the elimination of dental infection, the patients 
remain on a low level, as though they fail to have the mechanism 
functioning which should bring about the reestablishment of a 
normal defense and normal functioning. These cases are very 
slow to recover. In their case the prognosis is bad. They tend 
continually to recurrence and tend, in general, to have an un- 
favorable prognosis. We have endeavored to whip up the defense 
in these cases by various means such as autogenous vaccines and 
with very definite betterment in many instances. In some cases, 
however, in spite of the removal of the dental infections and the 
effort to whip up the defense with a vaccine, the results, as judged 
by the clinical improvement, have been very limited. This failure 
to improve physically has been paralleled by a failure of the ionic 
calcium to be improved toward normal. This has strongly sug- 
gested the absence of some activating substance which either 



432 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

combines with the toxic substance of the involved infections, or 
which reinforces the patient's defensive mechanism. 

In the chapter on Serological Studies we have showed the sug- 
gested relationship of the ionic calcium to the activity or normal 
functioning of the cells of the body. With an increase of the 
calcium beyond the normal, sugar readily passes from the blood, 
through the kidney, with the urine. We have tried the injection 
of ionic calcium in both rabbits and patients in such diminutions 
and quantities, as would make the absorption of the calcium 
readily possible, with limited success, as indicated by the raising 
of the ionic calcium of the blood. In some cases there would be 
a prompt improvement, which advantage would be lost, also, 
quite promptly. 

In thyroidectomized dogs it was early found that there was a 
tendency to development of tetany. It was later shown, however, 
that this was due not to the removal of the thyroid but the removal 
of the parathyroids, for the animals from which the thyroid 
was removed, without the removal of the parathyroid, could be 
kept alive by the administration of thyroid extract, but would die 
if the thyroid extract were not administered; and, similarly, the 
removal of the parathyroids, without the removal of the thyroid, 
produced a tetany and death which, however, could be prevented 
by the planting in the animals' tissues of parathyroid tissue. 
In either case the animals lived if a small quantity of both thyroid 
and parathyroid tissue was left. It was also shown that the re- 
moval of the parathyroids was accompanied by a depression of 
the ionic calcium of the blood, and that the injection of ionic 
calcium into the blood stream of an animal developing this 
tetany, relieved the symptoms. This has strongly suggested that 
the parathyroids are very directly related to the metabolism of 
calcium. 

I have, accordingly, endeavored to raise the ionic calcium of 
the blood by the administration of parathyroid extract to patients 
suffering from dental infections, from which they did not readily 
recover, after the removal of the dental foci. Such a case is the 
following : 

Case No. 1267. — A man, fifty-seven years of age, presented 
with the following history. His mouth was closed by swelling, 
which developed some months after the extraction of a mandib- 
ular molar tooth of the same side, some months previously. This 
operation had been made under gas, which excluded the possibil- 



CH w ww ii DEN I AL INFE< 1 IONS & i\ n k\ \1 SE( K'l.i IONS 133 

ity of the local anaesthetic's having lowered the defense, locally, 
of the tissue, or of infection having been carried in with the 
hypodermic needle. It was exceedingly difficult to make a physi- 
cal examination, due to the muscle spasm and the patient's pros- 
tration. He was so physically weak, that he had to be helped 
and almost carried into the ward. Pus was located and drained 
from the internal border of the ramus distal to the position from 
which the tooth had been removed, and no infection had de- 
veloped through the socket which had healed. This man had 
other dental infections which were removed, and the sockets healed 
slowly, but completely. There was a continual recurrence of the 
disturbance of the tissues about the left angle of the mandible, 
with a final cellulitis and lymph adenitis. Two enlarged lymph 
glands were opened surgically by his surgeon; by the maintenance 
of packs in these incisions, drainage was maintained, which 
wounds, if permitted to close, caused him immediate return of 
more acute symptoms. This involvement of his neck seemed 
quite distinctly separated from any possible zone of necrosis of 
the mandible. 

The ionic calcium of his blood, which would normally be about 
10 to 10.5 mgs. per 100 cc, stood at 7.5; and the use of tonics and 
the removal of dental infections failed to bring it up appreciably, 
suggesting an unfavorable termination, as the case was progres- 
sively getting worse. The clinical picture was complicated by a 
history of previous positive Wassermans. Parathyroid extract, 
one-tenth of a grain per day, was administered by me to determine 
its effect in increasing the ionic calcium of the blood, as 
well as upon his general clinical condition. In addition to the 
administration of the parathyroid I placed him on a diet, intended 
to increase, as rapidly as possible, his ionic calcium : namely, two 
quarts of milk a day, or preferably the same quantity of butter- 
milk, and two or four tablets of calcium lactate with each meal. 
Promptly the ionic calcium of the blood began to rise, increasing 
about 1 mg. per month per 100 cc. ; and with this improvement in 
ionic calcium, his physical condition improved ; the flowing fistulas 
in his neck and extensive induration subsided and completely 
disappeared; his general physical condition returned rapidly to 
normal, so that in five weeks' time he gained six pounds in weight, 
which was more improvement than is indicated by the weight, 
since a part of his previous weight was edema. He was able to 
take up his work in a few weeks' time, increasing his hours rapidly, 



434 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

and in approximately eight weeks was carrying his original 
heavy load with several extras; and in twelve weeks, according to 
one of his associates, was doing much more than an ordinary 
man's capacity of the hardest kind of mental and physical work. 

EFFECT OF PARATHYROID AND CALCIUM LACTATE TREATMENT 
ON IONIC CALCIUM OF BLOOD 



Date 


Hour 
A.M. 


Treatment for 
Ionic Calcium 


Ionic 
Normal 
Serum 


Ionic 
Treated 
Serum 


Combined 
Patho- 
logical 


8-31-22 


9:00 


Began 


7 5 


9.7 


2.2 


9- 6-22 


10:00 


Continued 


7 9 


9.9 


1.9 


9-13-22 


11:00 


Continued 


8.1 


9.5 


1.4 


9-26-22 


11:00 


Continued 


8 2 


9.4 


1.2 


1-24-23 


11:00 


Discontinued 


10 6 


11.0 


0.1 


2-16-23 




Resumed 


92 


11.1 


1.8 


4-25-23 




Continued 


9.4 


9.9 


0.5 



Figure 194. 

The progressive changes in this case are shown in the table in 
Figure 194. 

Another striking case is as follows : A young mother, who had 
had a miscarriage soon after the birth of her previous child, was 
suffering from rheumatism, probably related to dental infection. 
The ionic calcium of her blood was 8.2. In two weeks' time after 
the removal of her dental infection and with the assistance of 
parathyroid and calcium lactate, her ionic calcium had increased 
to 10.4, her rheumatism had disappeared, and instead of being 
discouraged and despondent, she had regained her normal state 
of vivacity, hopefulness, and pleasure in life. 

But all cases do not respond thus readily to the administration 
of parathyroid. In contrast with the above, I will cite the follow- 
ing: This patient had multiple deforming arthritis. His ionic 
calcium was reduced to 7 milligrams, with 3 milligrams patholog- 
ically combined. He was placed on a special diet of milk, calcium 
lactate, and a general mixed ration plus parathyroid. His con- 
dition improved but slightly, though definitely, but tended rapidly 
to settle back to his former condition. Removal of his dental 
infections did not materially improve his general condition which 
had existed for several years. The administration of parathyroid 
and calcium lactate only increased his ionic calcium from l l / 2 to 2 
milligrams. There was evidence that he was suffering from some 
other source of toxic involvement, that was so extensive, as to 



CHAP WWII l'lMAl IMIa rlONS & INTERNAL SECRETIONS 

keep him continually overwhelmed. He was referred to special- 
ists for the study of his digestive tract; and after being placed on 
a rigid rest treatment combined with hydrotherapy, he became 
more comfortable but with only slight improvement. They 
found a chronic colitis, which it seemed probable accounted for 
these symptoms and general reactions. The patient had felt 
definite improvement from the milk diet and requested that he be 
placed on that exclusively, of which he took four quarts daily. 
The result was that he experienced a marked improvement in the 
arthritic disturbances, and his ionic calcium coincidentally in- 
creased about four milligrams. We interpret these results as 
follows: 

On the milk diet, there was a distinct change produced in the 
bacterial flora of the entire intestinal tract, particularly of the 
colon, coincidentally, a change in the acid-base balance of the 
fluids of that tract. The toxic substances to which he had become 
sensitized and which were produced in that tract were reduced 
because of the reduction of the flora that had generated them. 
With the elimination of this toxic source, his blood was able to 
maintain its ionic calcium which otherwise was neutralized by 
this toxic substance, besides which there was undoubtedly a dis- 
tinct beneficial effect upon this local tissue from the presence of 
the milk products. The increased ionic calcium of the blood would 
rapidly raise the defense and repairing power of the diseased 
tissues of the colon; and just as the vicious cycle had tended to 
get worse and worse previously, similarly, by the increase in ionic 
calcium of his blood, the repairing power of the local tissue in- 
creased and the absorption of toxins decreased, the significance 
of which seems to be, that the administration of parathyroid and 
the forced intake of a calcium furnishing diet will be of no avail 
in a system suffering severely from the presence of a toxic genera- 
tion and absorption of the same or similar type as that in a dental 
focus with which we are concerned; and this explains probably in 
large part why the removal of the dental infection produces in 
many cases either a temporary or a limited beneficial effect. 

IV. THE IMPROVEMENT OF THE FUNCTIONING OF THE 
GLANDS OF INTERNAL SECRETION BY THE MECHANICAL 
STIMULATION INDUCED BY THE MOVEMENT OF THE 
BONES OF THE FACE AND BASE OF THE SKULL. 

One of my earliest experiences, in this connection, was with a 
case which showed conspicuously the interrelationship between 



436 DENTAL INFECTIONS, ORAL AND SYSTEMIC—RESEARCHES— VOL. I 

the pituitary and the development of the bones of the face. This 
boy at the age of sixteen was infantile in many of his character- 
istics and developments. The genitals were those of a boy eight 
years old. The facial expression was that of the typical Mongo- 
lian idiot. By the Binet test he had a mentality of about four 
years. Roentgenograms of his hands showed that the epiphyseal 
bones had not united. He played on the floor with blocks and 
with rattles like a child. His interest was in children's activities. 

The characteristic physical condition was that his maxillary 
arch was so much smaller than the mandibular arch that it went 
entirely inside it. In order to give him a masticating surface and 
with the hope of helping him both physically and mentally, since 
I had had several cases greatly benefited by such an operation, I 
determined to widen his arch by moving the maxillary bones apart 
about one-half inch. The position of his teeth before is shown 
in Figure 195-D. Roentgenograms showing the opening of the 
median suture with increase of pressure are shown in Figure 196. 

An important phase of this case was that the left nostril was 
entirely occluded and had been probably all his life. A rhinol- 
ogist spent a half hour trying to shrink the tissue with adrenalin 
and cccain sufficiently to get air or water through, and was not able 
to do so. He was able to breath only through his mouth. The 
quantity of air that he was able to secure through his right nostril 
was so scant that he continually breathed with his mouth open. 
At night he was forced to lie with something like his coat rolled 
into a ball and placed under the back of his head and his head 
pushed far back so that this position would open his mouth and 
retain it so, or he would awaken by strangling himself with the 
closing of his mouth. 

He had the innocence and utter lack of sense of modesty of a 
child; would undress under any conditions before strangers. 
With the movement of the maxillary bones laterally, as shown 
progressively in Figure 196, there was a very great change in his 
physical development and mentality. He grew three inches in 
about four months. His moustache immediately started to 
grow ; and in twelve weeks' time the genitals developed from those 
of a child to those of a man. His mentality change was even more 
marked, as the median space between the maxillary bones was 
widened to one-half inch in about thirty days, and by some proc- 
ess which I have interpreted as probably being a prying down 
of the base of the skull, thereby reducing by the leverage of the 



CHAP. XXXVII DENTA1 INFECTIONS & INTERNAL SECRETIONS Ktf 




A. Fremt vlow before. 



B. Front view thirty days later than A. C. Front view si* months later than A. 



Figure L95. Front view. Changes produced by slowly opening the median suture. Case No. in. 
V.I sixteen. In ABOUT TWELVE WEEKS he passed THROUGH THE changes of adolescence, rapidly 

GROWING A MUSTACHE. ETC. 




Figure 195. Side view. Changes produced by slowly opening the median suture. Case No. ill. 
Age sixteen. The mental changes were also very great. He passed from playing with blocks to the 
interests of developing boyhood, telephoning, reading, etc. 



438 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 







Figure 196. Roentgenographs changes by days from opening the median suture. 



CHAP.XXXVI1 DENTA] INFECTIONS & INTERNA! SECRETIONS 139 

maxillary boms on the temporal bones, a pressure upon the 
hypophysis cerebri or pituitary in the sella turcica, and thereby 
markedly changing its function. In a few weeks' time he passed 
through stages that usually take several years; at first, getting 
behind the door to frighten us. later, putting bent pins on chairs 
to see us jump when we would sit down, and finally being the 
cause of a policeman's coming into the office from where he was 
conducting traffic on the corner below to find who it was squirting 
water on him when his back was turned. He developed a great 
fondness for calling people over the telephone, wanted to borrow 
my automobile to take his mother for a drive, and with his arm 
caressingly about the shoulders of one of the secretaries invited 
her to go with him to Euclid Beach for a dance. All this change 
developed in about twelve weeks' time. 

A most remarkable event happened in connection with this 
procedure. He lived in another city, and so, while with me was 
kept in a boarding house at a little distance from my office in order 
for frequent and necessarily constant attention. On his return to 
his home town with the appliance to maintain the separation in 
place, his efficiency had increased to such an extent that his 
mother would send him with the money to the grocery store with 
the order for the day's groceries, and he could invariably bring 
back the right change and could tell when it was correct. He 
could also come to me that ninety miles by railroad and make two 
changes of trains and the various transfers on the street cars of 
the city with all the exactness of a normal adult. 

But this appliance became dislodged; the maxillary bones set- 
tled together; immediately, or in a day or two, he lapsed into his 
old condition of lethargy accompanied by an old trouble, which 
had frequently been distressing, of nausea, sometimes lasting for 
twenty-four hours. With the readaptation of the separating 
appliance and the reconstruction of the retaining appliance he 
returned again to his other state. 

But a new problem had been developed. We had changed an 
infant to a potential man with all of the instincts and impulses of 
a man but with the mind of a child. It became necessary for his 
family to make changes because of the death of his mother, and the 
marriage of his sister, and he was accordingly placed in a state 
institution where he was lost in the herd, all receiving approxi- 
mately the same care. During this period under which he was 
in my care he had learned to read and spent much time doing so. 



- 440 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

Figure 195 shows his appearance before and after the operation, 
there being only thirty days' difference between each A and B, and 
D and E, side view. C and F show, respectively, the front and 
side views six months after the first picture, and it will be noted 
that his whiskers and moustache had started to grow. He now 
has the face and potentialities of a man. 

In this connection I would refer to another case where a boy of 
eight years had less marked depression of the maxillary arch but 
a very marked depression mentally, such that he was not able to 
be taught with other children. An important characteristic of 
his case was that he was as timid as a bird and as dependent as an 
infant, was afraid of all children who might in any way cross him 
for fear they might hurt him, and was extremely docile to his 
parents. After the separation of the maxillary bones, similarly, 
though not so extensively, as in the latter case, his condition im- 
proved so greatly that his mother could send him to the store 
with the money to buy provisions and groceries and he could 
return with five articles which he would buy himself, and not 
forgetting even one. He also became the bully of the street; 
would come into his home boasting about how he had smashed 
such a big boy's nose for crossing him in something; and finally 
when his mother chided him for something that he did not wish 
to do, stating that she could not have anyone in her home who 
did not mind, he promptly told her that if she insisted on his 
doing that thing that he would leave the home. This was a com- 
plete change from his former lack of assertiveness and capacity for 
individual defense and responsibility. Unfortunately, domestic 
conditions made it necessary for this boy to be moved away from 
this city and for three years he was out of my care and received 
no attention. The final results were not so good as they should 
have been because of this neglect, though he never lost his asser- 
tiveness and capacity for taking responsibility. 

SUMMARY AND CONCLUSIONS. 

We would summarize these studies as follows: 

(1) Disfunctions of various of the glands of in- 
ternal secretion are often very materially corrected, 
and sometimes completely so, by the removal of 
dental focal infections. 

(2) Involvements have frequently been produced 



CHAP WWII DENTA1 INFECTIONS & INTERNA! SECRETIONS 111 

In similar endocrine tissues of the animals by in- 
oculating them with the cultures from the teeth 
of the involved patients. 

3 The administration of the extracts of the 
glands of internal secretion, particularly of the par- 
athyroid, is shown to be of distinct benefit in cer- 
tain cases of depressed ionic calcium of the blood, 
due in part to dental focal infections, where this 
improvement has been absent or slow following the 
removal of the dental infections. 

4) An improvement has been produced in indi- 
viduals, which we interpret to be due to a stim- 
ulation of the pituitary body, which in turn doubt- 
less stimulates other ductless glands and together 
with them produces a marked change in both 
physical and mental states. 

See bibliography references 20, 21, 22, 23, and 24. 



CHAPTER XXXVIII. 

THE NATURE AND FUNCTION OF THE DENTAL 

GRANULOMA. 

PROBLEM: Is a dental granuloma a pus sac and its size 
a measure of the infection and danger? 

EXPERIMENTAL AND DISCUSSION. 

It is not without significance that the members of the laity 
speak of the structure which is frequently attached to an ex- 
tracted root as a pus sac and something greatly to be feared and 
dreaded. They have very correctly reflected the thought of the 
professions. These researches have been undertaken to har- 
monize, if possible, the data that have been developed in the pre- 
ceding researches here reported and the current opinion. If we 
were to express the public and professional evaluation of this 
structure it would be as follows : 

Since a dental infection, if present, will produce an apical 
abscess, the size of that abscess will be the measure of that infec- 
tion; and if it be particularly bad, it will produce a pus bag or sac 
which may or may not contain pus, but which is always an evi- 
dence of considerable infection. 

In Chapter 3 on The Local Structural Changes Produced by 
Dental Infections, we found (1) that there is a large variation in 
the periapical structural changes that will be produced with an 
apparently given quant ty of infected pulpal irritant, sufhcient 
that these individuals may be graded from those having large 
apical involvements associated with, for example, a putrescent 
pulp; (2) those with this large area of apical involvement but 
which, instead of being diffused into the cancellous structure, is 
surrounded by a more or less definite zone of condensed structure, 
a condensing osteitis surrounds the zone of rarefying osteitis ; (3) a 
very limited zone of destruction of apical bone with frequently a 
tendency to a dense bone surrounding the apical area. 

In Chapter 4 we found that there is a very great difference in 
the susceptibility of individuals to injuries from dental infections 
expressing themselves as rheumatic group lesions. 

In Chapter 5 we found that the individuals with the high de- 

442 



CHAP WW ill NATURE & FUNCTION OF DENTA1 GRANULOMA 143 




Figure 197. Appearance of a degenerating granuloma. Patient has lost her defense. Insert shows 
roentgenographs appearance. 



s - 



■ 









* - tJm. ** V 





Figure 198. A protective mechanism of dental granulomata. 

444 



CHAP. XXXVIII NATURE & FUNC HON OF DENTA1 GRANU1 OMA 1 15 

fense which protected them against injury from their dental in- 
fections expressing themselves systemically as rheumatic group 
lesions) had invariably a relatively larger zone of rarefaction or 
bone destruction about the apex of an infected root, than did the 
individuals without that defense, in whom the dental infections 
expressed themselves readily as rheumatic group lesions; and 
that the individuals showing the zone of condensing osteitis 
surrounding the zone of rarefying osteitis generally proved to be 
individuals whose defense had previously been high and had been 
reduced, which latter we termed a state of an acquired suscepti- 
bility. This latter classification was based not on this local struc- 
tural condition, but on the fact that the patient, that had pre- 
viously had complete freedom from rheumatic group lesions, had 
suddenly acquired that condition, hence an acquired suscepti- 
bility. 

Subsequent chapters revealed that dental caries tended to be 
much more dominant in the individuals with rheumatic suscepti- 
bility, and periodontoclasia tended to be more prominent in the 
individuals without the susceptibility to rheumatic group lesions. 

In the chapters on serological and chemical changes in the 
blood and fluids of the body, the data revealed that in the individ- 
uals with a high defense, the ionic calcium of the blood tended to 
be high ; and that it tended to be lower than normal in those with 
a rheumatic susceptibility; and that in the same individual, 
generally just in proportion as the ionic calcium returned to nor- 
mal, the rheumatic group symptoms disappeared ; also that these 
variations were produced regularly in animals by the introduction 
of dental infections either by inoculations or by the planting of the 
infected tooth beneath the skin. 

These studies, and the data they revealed, strongly suggested 
that the tissue which developed at the root apex, and which was 
present in relatively larger quantities in those individuals with a 
high defense, was a defensive tissue placed there by Nature to 
establish and maintain a quarantine as close as possible to the 
source of infection. I, accordingly, have made a very careful 
study to ascertain the nature of the tissue producing this quaran- 
tine and have found a very large range in the types of tissue found 
at root apices. Figure 197 shows a granuloma removed with the 
tooth of a patient who up to six months ago had a very high de- 
fense and no rheumatic group symptoms, but during the past six 
months following a cold or Flu she has had quite persistent neu- 






%V^. : :M. ■:;-:■ :- \ 

\ ■ • 'X 




Figure 199. Highly vascular granuloma of Figure 198. 

446 



CHAP WWII! NATURE & FUNCTION OF DENTAL GRANULOMA II. 

litis. Note the very large lumen in this granuloma, consisting of 
necrotic tissue, leucocytes, and bacteria. The insert shows the 
in ntgenogram Of the tooth before extraction, and it will be noted 
that time is a definite zone of condensing osteitis surrounding 
the an a of rarefaction. 

In Figures 198 and 199 we see in contrast with this a granuloma 
which is intact, very highly vascular (shown in high power in 
Figure 198-B) with no necrotic and degenerated tissue, and with a 
very distinct epithelial membrane in contact with the root apex. 
These two quite divergent pathological structures are but two of 
a very wide range which night be inserted; and they and the 
structure represented in Figure 200 are presented here simply to 
suggest the extreme variation that may occur in these apical 
tissues. 

In Figure 200 we see a very limited amount of fibrous capsule 
lying close to the denuded root end, almost entirely without vas- 
cularization, with a purulent exudate between the membrane and 
the tooth. I will later discuss and interpret these conditions. 

If the dental granuloma is simply Nature's method of encysting 
a foreign substance or an irritant, it must be considered a quite 
different structure from that which Nature will build into a zone 
as the result of irritation, in which case the irritation would pro- 
duce a proliferation and hence, as its name implies, a granuloma, 
for this is, we take it, the origin of the name that this tissue has 
taken. For example, Dorland's definition of a granuloma is as 
follows: "A tumor or neoplasm made up of granulation tissue. 
Dental g., a small mass of granulation tissue containing bacterial 
depcsits on the root of a tooth." Anthony's is: "A tumor-like 
ncdule or area of granulation tissue. Dental g., granulation tissue 
abcut the apex of a tooth usually containing bacterial deposits. 
Chronic inflammatory pericementitis." Ottofy's is: "A collec- 
tion of leucocytes and epitheliod cells which surround the central 
point of irritation and resemble granulation tissue. Dental g., 
granulation tissue, without suppuration, at the apex of the root of 
a tooth or in some edentulous tissues." 

Our first line of approach was to determine what Nature's re- 
action tends to be to mechanical irritants, in order that we might 
distinguish clearly between mechanical irritation and bacterial 
irritation. To determine this, I placed various foreign substances 
in the tissue under the skin of rabbits and found that if the object 
were sterile when inserted, Nature developed a very slight trans- 




Figure 200. Resorption processes in C and D, from point of arrow in B; A, roentgenographs appearance. 

448 



(WW WW III NAT! RE & M V HON < >i DEN1 \l. GRANULOMA 



149 



» 







Figure 201. 

formation. 



Appearance of dime planted two months. Note no cyst 



parent fibrous tissue about it with no tendency to proliferation or 
development of granulation tissue. This is well illustrated in Fig- 
ure 201 which shows a dime so encysted in the tissue of a rabbit, 
it having been placed beneath the skin in this position two months 
previously. These have been left for longer and shorter periods, 
and the only change that is apparent is a definite evidence of 
etching and solution of the metal. It may be answered that this 
is due to the formation of albuminates with the silver and that 
the effect would be different with other metals. We have found 
little or no difference whether the foreign irritant was a piece of 
sterile glass or a piece of any one of the ordinary metals. It will 
be noted that the inscription on the dime, shown in Figure 201, 
can be read through the capsule as though there were no inter- 
vening tissue. 

When we have placed teeth beneath the skins of rabbits or in 
other tissues such as the muscle, as we have now done over a 
hundred times in various studies, we find a very great difference 
in the effect. If the tooth has been free from infection, as, for 



450 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

example, a freshly extracted impacted third molar, there is very 
little more tissue built around it than around the dime shown in 
Figure 201. If, however, it was a pulpless tooth, with or without 
root filling, there is a very great difference in the reaction which 
it produced, ranging all the way from a closely adherent fibrous 
capsule entirely surrounding and enclosing the tooth, to the com- 
plete absence of a capsule, the tooth being found in a well of in- 
flammatory exudate, sometimes with a quantity of leucocytes 
dead and living, and sometimes with practically no leucocytes 
and a pure culture of streptococci. In either of the latter cases 
when no capsule was formed, the rabbits were invariably killed 
in from a day and a half to a few weeks; and generally in less than 
six days. When these teeth were surrounded by a capsule they 
were often carried many months or a year if the rabbits were not 
chloroformed and posted earlier for study. 

Figure 202 shows a group of encapsulated teeth that had been 
in the bodies of rabbits for periods of weeks or months, several 
of them six months. In many instances the rabbits did not show 
the slightest evidence of injury from these teeth. In some others, 
even though they were carried for weeks and had become entirely 
encapsulated and showed no evidence to develop local abscesses 
about the teeth, the rabbits developed degenerative diseases such 
as involvements of the heart and kidneys. Figure 203- A shows a 
rabbit with such a tooth placed beneath the skin, which had been 
taken from the mouth of a patient with nephritis. The rabbit 
developed acute nephritis, as evidenced by albumin in the urire, 
development of casts, and parenchymatous degeneration of the 
kidneys, as shown in B and C. In Part Two, other volume, in 
the study of the relation of dental infections to the degenerative 
diseases, I show in Chapter 63 on Nephritis a case where the 
same tooth placed under the skin of two different rabbits de- 
veloped nephritis in two rabbits in succession, where the tooth 
had been taken from a patient suffering from acute nephritis. 

Invariably when the rabbit built a capsule about the tooth, it 
proceeded to absorb the tooth ; and the process is not distinguish- 
able histologically from that process when it takes place in the 
mouth. Figure 204 shows a cross section of one of these fibrous 
capsules developed by the rabbit in comparison with the structure 
built about a tooth by the human; and it will be noted that, his- 
tologically, it is practically impossible to distinguish which tissue 
was taken from the rabbit and which from the individual. It does 



CHAP WW 111 NATURE & FUNCTION OF DENTA] GRANULOMA 15] 




Figure 202. A group of encapsulations about implanted teeth, produced by the rabbits \\n the 

ROENTGENOGRAPHS MEWS OF SAME. NOTE ABSORPTION OF TOOTH, B-l. C-l D-l. 



452 DENTAL INFECTIONS, ORAL AND SYSTEMIC -RESEARCHES— VOL. I 



* VAJ 




•'*£ 




».s 









*• j 



s 



*.- 



\ * 





Figure 203. A shows, roentgenografhically, a tooth implanted beneath the skin of a rabbit, which had 

BEEN REMOVED FROM A PATIENT SUFFERING FROM NEPHRITIS. B AND C SHOWS TWO SECTIONS OF THAT RABBIT'S 
NEPHRITIC KIDNEY WHEN IT WAS CHLOROFORMED SOME WEEKS LATER. 



CHAP. XXXVIII NATURE & FUNCTION < >F DENTA1 GRANULOMA 



153 







'5k 




i 

■ 






I 

■ 







Figure 204. Two granulomata. The left was developed by the rabbit about the implanted tooth; the 

RIGHT BY THE PATIENT FROM WHOM THE TOOTH WAS EXTRACTED. 

not seem justifiable to think of the protective tissue built by the 
rabbit as a neoplasm; but, if so, why less justifiable so to think of 
the structure built about the same tooth by the patient from 
whom it was extracted. With regard to the histological picture 
presented by a tissue engaged in the process of absorption of the 
root of a tooth, it will be noted that it is also not possible to dis- 
tinguish between the structures engaged in this operation, whether 
taken from the human or the rabbit. 

If, then, all rabbits were affected systemically if they did not 
succeed in building a protective membrane about the tooth, while 
all survived apparently uninjured if they succeeded in doing so, 




Figure 205. Shows an abscess produced under the skin of a rabbit by the implantation of a 
root of the molar shown in c. see text. 



454 



CHAP. XXXVIII NATURE A F\ NCTION OF DENTA1 GRANULOMA 155 

we find to tins extent a co-operation of our interpretations as 
made in preceding chapters. But this is not all the evidence here- 
with developed. It may be argued that while a tooth d<x's not 
furnish either teacupfuls or quarts of organisms, there is still too 
ureal a quantity of infection for a rabbit to neutralize. If this 
be true, one rabbit should neutralize some part of the infection 
and toxin of a given tooth, and if that tooth should be transferred 
immediately to another healthy rabbit, we should expect that 
soon all of the poison in that tooth could be neutralized by the 
several rabbits. Assuming that an individual is twenty times as 
large as a rabbit, twenty rabbits might be expected to furnish 
enough neutralizing power to destroy this activity, whatever it 
may be in a given tooth. This has been tested incidentally in 
connection with another problem in which the same tooth was 
planted beneath the skin of thirty different rabbits, twenty not 
proving to be sufficient, and the last dying in as short a time as 
the first, and all but one within six days after the tooth was placed 
beneath the skin of the rabbit. One lived ten days and it was an 
exceedingly large and vigorous male who was so ugly a fighter that 
he tried to kill any other males that were put into the same cage. 
Within six hours after the tooth was planted beneath the skin, all 
this pugnacity and viciousness had disappeared, and in a couple 
of days the typical blood changes with loss of weight appeared. 
In the chapter on calcium in relation to dental infections I 
have referred to the fact, that the ionic calcium of the blood of 
individuals affected with dental infections, is practically always 
depressed at the time that they are suffering from rheumatic 
group lesions; and, further, that if the patient's tooth be placed 
in the serum of that patient's blood, the ionic calcium is still fur- 
ther and very rapidly lowered, in some instances almost entirely 
removed from the serum. It can be regained by chemical pro- 
cedure, as I have shown, for it is apparently in what I have termed 
a pathologically combined state with the toxin from the tooth. 
In these rabbits in which teeth have been planted beneath the 
skin, there has been a marked difference in the change of ionic 
calcium of the blood whether the animal succeeded in building an 
encapsulation about the tooth, in which case it generally lived for 
weeks or months, or whether it was unable to do so. In the for- 
mer the ionic calcium remained practically constant and normal, 
while in the latter it was always reduced. With the reduction of 
the ionic calcium there was always a loss in weight of the animals 



456 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

and the decline was practically in direct proportion to the de- 
pression of the ionic calcium, so much so that we could tell almost 
precisely when a rabbit would die by plotting the curve as the 
calcium was going down. This is shown in Figure 136 in the chap- 
ter on changes in blood calcium. I have stated, as was shown in 
very many cases in our rabbit posts, that invariably if the rabbit 
failed to build quickly an encysting membrane about the tooth, 
death followed promptly and practically always within ten days, 
in the majority of instances in five days or less, and often within 
two days. We can scarcely imagine a concentration of poison so 
profound that the small quantity that would be present in an 
ordinary root-filled tooth could overwhelm thirty rabbits in suc- 
cession from a single tooth, and in which all the other teeth from 
that same patient produced the same effect. We are evidently 
dealing here with forces that are different from those that enter 
into our ordinary conception of cause and effect. In preceding 
chapters I have shown that by washing the crushed tooth and 
passing the washings through a Berkefeld filter and having a 
small quantity of apparently clear water left, I would have a sub- 
stance which, when inoculated into the rabbits, would frequently 
start them on a decline, even though it was bacteria-free as proven 
by culture, and which decline would frequently terminate in 
death in a few weeks, and practically always with a depression of 
ionic calcium and of body weight. 

In the chapter on the efficiency of root fillings (Figure 105) I 
have shown a case where a tooth, the second molar, was root-filled 
by us a year previously because we considered it a favorable con- 
dition to sterilize and root-fill. The roentgenograms of these 
teeth and one of the rabbits with the root implanted are shown 
in Figure 205. A shows the tooth before treatment and root filling, 
B immediately after root filling, and C seventeen months after 
root filling. The results of the root filling were quite satisfactory 
in accordance with the teachings available for the profession at 
this time. Roentgenographically the very slight zone of rare- 
faction at the apex of the root had grown less. But the patient 
was not as well as she should be, with symptoms which I sus- 
pected might be related to this tooth; and because of the great 
improvement she had had from other extractions, she desired to 
have it removed. This we did. The two roots of this molar were 
placed beneath the skins of rabbits. One root, the mesial, evi- 
dently contained much more toxic substance than the other for, 
as shown, the first rabbit died in six days. The subdermal abscess 



CHAP. XXXVIII NATURE & FUNCTION OF DENTA] GRANULOMA 157 

is shown in Figure 205-D. The tooth was replanted in anothei 
rabbit which died in eleven days. Before it was replanted and 
after it had killed the first rabbit, I drilled into the apex at the 
foramen of the tooth alter sterilizing the surface (these teeth arc 
always thoroughly cleansed externally before being transferred to 
another animal) and cultured the borings and found that they 
contained a pure strain of streptococci, notwithstanding the 
splendid appearance of the root filling. The rabbit in which the 
other root, the distal, was implanted was able to encapsulate it. 
It died in twenty-three days. This root was then transferred to a 
second rabbit and it in turn encapsulated the root and died in 
thirty-seven days. 

It should be noted that the second rabbit in each of these cases 
lived much longer than the first, which has a direct bearing on a 
criticism of this work, which I refer to elsewhere, to the effect that 
I was overlooking the fact that animal passage makes infections 
more virulent, which accounted for the more rapid death after 
the first implantations in the case which was under discussion: 
namely, where I had drilled several small openings through to the 
interior of the tooth to permit more free exit of the toxic and 
bacterial substances. (See Chapter 17, on Quantity, Systemic 
Effect, and Tooth Capacity.) 

The mesial root was again planted beneath the skin of a rabbit 
and it died, spontaneously, in five days; and still another implan- 
tation was made and the rabbit died in four days. Each one of 
the rabbits developed, besides the large subcutaneous abscess, 
such lesions as hyperemia of the myocardium, liver, and kidneys, 
acute myositis and atrophy of the chest and abdominal muscles, 
all with emaciation. The four rabbits into which the mesial root 
was planted lived on an average six and one-half days and had an 
average actual loss in weight of 256 grams, or 20 per cent, and an 
average loss per rabbit per day of 3.3 per cent. The two rabbits 
treated by planting the distal root, subdermally, died spontane- 
ously in an average of thirty days, with an average loss of weight 
of 478 grams, or 31 per cent, or 1 per cent per rabbit per day. 

The mesial root was then boiled for ten minutes and placed 
under the skin of a rabbit, which rabbit is still living at the time 
of this writing, fifty-one days after implantation. Apparently, 
the boiling did something to this tooth, for, whereas the other 
rabbits failed rapidly and died apparently from the effect of hav- 
ing this tooth implanted, this rabbit has gained from 852 grams 
to 1080 in the fifty-one days, a total gain of over four grams per 



458 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

day. This rabbit, therefore, has had a gain of weight of 21 per 
cent in fifty-one days, or 0.4 per cent per day. It should also be 
noted that this rabbit had the same surgical shock that the others 
did. I desire to warn that it is not fair to conclude, however, that 
this method of treating suspected teeth — namely, to remove them 
and boil them and replace them — will always be as adequate 
as this, since, as I have shown elsewhere, these teeth often con- 
tain a toxic substance which is thermostabile and which con- 
tinues to do some, though less, injury even after the tooth has 
been boiled. 

These facts strongly suggest that the structure that is built 
about the root of an infected tooth is not a neoplasm, but that it 
is a protective membrane placed there by Nature to maintain a 
quarantine and thereby protect the animal or person carrying it. 
With this in mind, we have made a careful analysis of the condi- 
tion of this tissue about the root apex in the various types of in- 
dividuals presenting, and we have found that the type of tissue 
shown in Figure 198 of this chapter, is practically always present in 
individuals without rheumatic group lesions or apparent systemic 
affect from dental infections which they are carrying; and that if 
this normal high defense which has enabled them to produce this 
type of quarantine has been broken, there is a definite degenera- 
tion of this organ surrounding the apex of a tooth, and it takes on 
a condition such as that shown in Figure 197, which is the typical 
clinical state of the granuloma as found in individuals with a 
broken defense; and, further, that in those individuals, who have 
a chronically low defense, there is never an ample effort made to 
build such a quarantine station about the tooth. It is not well 
organized nor extensive in quantity, and we frequently, if not 
generally, find free organisms between this tissue and the root 
end. This type is illustrated in Figure 199. From a bacteriological 
standpoint in the individuals with either a chronically low defense 
or a recently acquired loss of defense (those with acquired sus- 
ceptibility), we not only have the lack of well vascularized defen- 
sive tissue, but we have the definite evidence of infection in the 
form of organisms and very few phagocyted leucocytes; whereas 
in the periapical tissues of the individuals who have at that time 
an ample and high defense, we not only find a complete absence of 
organisms, but we do find both a highly vascularized tissue and 
the tissue elements necessary for an active defense: namely, 
many leucocytes, some of them phagocyted. 



CHAP. XXXVIU NATURE & FUNCTION OF DENTAL GRANULOMA 159 

An illustration of one of Nature's mechanisms is shown in 
Figure L98-A and B. This show sin A the relation of the periapical 
defensive tissue to the root apex. It will be noted that there is 
little depression in the granuloma just over the exit of the apical 
foramen. This is shown highly magnified in B; and it will be 
noted that it is lined with a vigorous membrane of columnar 
epithelial cells, each with a well defined nucleus, and all of which 
have taken the stain vigorously, showing evidence of splendid 
vitality; and this seems to be the first line defensive tissue, 
for it is the type of tissue that Nature has built throughout 
the alimentary tract to defend us against the absorption of 
bacterial toxins. It is not strange that Nature should use the 
same effective mechanism here which she does in that extensive 
portal for bacterial and toxic entrance into the system. 

If, then, as these data suggest, the dental granuloma so-called 
is not a neoplasm — in other words, is not a pathological tissue but 
a physiological tissue, whose function is to defend the individual 
against bacterial and toxin invasion, — we should have evidence of 
this quality by other means of observation. To test this I have 
placed various types of granulomata in both suspensions of or- 
ganisms and freshly infected culture media with the remarkable 
result that whereas in the tube with the degenerating granuloma 
there is very little power to destroy bacteria in its vicinity, the 
vigorously functioning, freshly removed granuloma destroys the 
organisms in its vicinity in its tube, or at least there is developed 
a clear space in infected culture media for some distance surround- 
ing the granuloma tissue. A bacterial count of the total fluid in 
the tube with the well organized granuloma shows a reduction 
from one-half to one-third that of the control tube. 

A vigorously functioning granuloma should develop about the 
root of a tooth, carrying either a considerable quantity or a very 
toxic infection, such quantity as develops in practically any tooth 
providing the capacity of the dentin for bacterial growth and in 
addition the pulp chamber; and any patient who has this quantity 
of infection and does not produce such a defensive mechanism is 
not only in danger of being early affected, but in most instances is 
already being affected by the contents of that tooth. Such a con- 
dition is shown in Figure 206. This patient has carried this tooth 
for years. It has a fistula and he is in splendid health. 

It is a most remarkable fact that when we study our old people 
who have lived through all the overloads incident to life and ex- 



460 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




Figure 206. A vigorously func- 
tioning GRANULOMA IN A PATIENT OF A 
HIGH DEFENSE. 




Figure 207. The roentgenographs and photo- 
graphic VIEWS OF GRANULOMATA WHICH PROTECTED THE 
PATIENT UNTIL ABOUT EIGHTY YEARS OF AGE. 



tensive dental infections, and who in spite of them all and, par- 
ticularly, in spite of what seemed to be extensive dental infec- 
tions, are still well or relatively so for their age, we find this type 
of reaction about the roots of teeth. Such a case is shown in 
Figure 207. This patient, about eighty years of age, has several 
such teeth as this. C and D show the roentgenographic appear- 
ance of these two teeth, the lower right second molar and lower left 
second molar. Throughout her lifetime she has never suffered from 
neuritis, rheumatism, or nervous breakdown; and, incidentally, 
those disturbances are practically unknown in her family. A full 
set of roentgenograms of her case and also her brother's is shown 
in Figure 34 Chapter 3. When we study these teeth in connec- 
tion with Nature's quarantine — namely, this vigorous, well 
vascularized, periapical encapsulation, — we see why she has had 
her protection. Incidentally, however, she has developed re- 
cently a kidney irritation which has entirely disappeared with the 
removal of these dental infections. Even her splendid defense 
has lately been breaking. 

We do not yet know the full meaning and function of the epi- 
thelial structures which Nature builds into these highly efficient 
quarantine stations, but it seems very evident that it is not acci- 



i II \V WW III NATURE & II NCTION OF DEN I \l. c.K \\l l.< >\1 \ K.l 




J% 

















- 



i >*$& 



"m 



N\<' 









SWw 



B 




Figure 208. A highly functioning granuloma. Note the large amount of epithelial 

TISSUE. 

dental that this structure, when most efficient, carries a very 
large amount of epithelial tissue. This is illustrated in Figure 208, 
which is from the tooth of a patient with exceedingly high de- 
fense, the roentgenographic view of which is shown in A. It 
should not be presumed, therefore, that those individuals, having 
a high defense, as expressed by their capacity to build an efficient 
quarantine station about an infected root, are safe both for the 
present and future. To test this I have planted teeth in rabbits, 














B 






Figure 20 ). An implanted tooth which the rabbit carried thirteen months. It died 

OF NEPHRITI 3, FROM WHICH THE PATIENT WAS SUFFERING. C. THE ENCAPSULATED TOOTH; B, CASTS 
FROM THE RABBIT'S URINE. 

462 



CHAP. XXXVIU NATURE & 11 NC I ION OF DEN I \l. GRAN1 LOMA 






and where they had built a high defense I have kept them under 
favorable conditions for long periods to see what the effects would 
be. Recently two of such test rabbits have died with nephritis, 
where the teeth had been implanted over a year previously and 

about which the rabbits apparently built adequate defense but in 
which contest the rabbit finally lost the fight. Figure 209 shows in 

A a dissection of a posted rabbit where a large broken down cyst i-- 
shown. It is remarkable that the animal gained from 975 grams 




J 



\ 




















■* JF 



Figure 210. A sterile implanted tooth which produced practically no 

ENCAPSULATION. 



464 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

to 2885, nearly three times its original weight, in eight months, 
when it started to decline, and died thirteen months after the 
implanting of the tooth, with a weight of 2010 grams, having lost 
from its maximum weight 875 grams, or 30 per cent. Figure 209-B 
shows casts from this rabbit's urine, and C shows the encapsu- 
lated tooth. It is important to note that this patient was suffer- 
ing from acute Bright's disease at the time of the removal of her 
tooth. 

It is very important to note the very great difference in the 
local structural changes about a tooth which may stay for a long 
period of time under the skin of a rabbit and produce no evi- 
dence of injury to the rabbit. Whereas in the last case the tooth, 
which was potentially able, we believe, to do injury to both the 
patient from whom it was taken and the rabbit, was tolerated for 
a long time by the rabbit, it had built about it a very vigorous 
and well vascularized defensive tissue. When sterile, non-irri- 
tating, foreign substances, as illustrated in the coin in Figure 201, 
are planted beneath the skins of rabbits, there is not only no 
systemic disturbance, but there is practically no local reaction. 
This is what happens also when teeth that are implanted are free 
from irritating substances. In other words, they lie in the tissue 
without encapsulation, covered only with a membrane so thin 
and transparent that the tooth can be seen almost as perfectly as 
if it were not encapsulated. Such a tooth is shown in Figure 210, 
which remained in a rabbit for sixteen months, when the rabbit 
was chloroformed to study its structure. During this time it had 
gained progressively from 1603 grams to 3034. This tooth was 
removed from the patient not because of roentgenographic evi- 
dence that it was in error but as a matter of precaution, the patient 
having had a serious injury from a previous dental infection. It 
is my belief that this tooth was not injuring this patient. 

In a previous paragraph of this chapter I discussed the fact, 
that even boiled teeth seemed to contain toxic substance. It is 
quite important that, whereas implanted teeth that are apparently 
entirely free from infection, such as some of our surgically re- 
moved impacted third molars, produce practically no encapsula- 
tion such as the last tooth showed. The boiling, or even auto- 
claving, of teeth does not always destroy all the toxic substance. 
We do not yet know the full significance of this except that the 
toxin seems to be thermostabile and we have found evidence of 
this, (as shown in Chapter 30 on Sensitizations, where the extract 



CHAP XXXVIII NATURE & FUN< HON OF DENTA1 GRANULOMA 165 

taken from teeth was found to product' the typical intradermal 
skin reaction) in main- instances, each when passed through a 
Berkefeld filter, when sterilized chemically, when boiled for an 
hour, when autodaved at thirty pounds, and also when autoclaved 
at three hundred twenty pounds for two hours. 1 was. therefore, 
not surprised to find that there was a distinct difference in the 
reaction locally and on animals when boiled teeth had been in- 
fected. Boiled and autoclaved infected teeth have encapsula- 
tions developed about them almost invariably. But this is not 
the most important part of it. Very often the rabbits carrying 
these teeth show blood changes within a couple cf weeks and begin 
losing in weight. Figure 211 shows the typical appearances of the 




Figure 211. Encapsulations about boiled infected teeth. Heating did not destroy the toxin. 

encapsulations about three such boiled teeth. A was boiled for 
one hour. The rabbit (No. 1165) died in twenty days, with a 
loss of 160 grams, or 9 per cent. It is impossible to state definitely 
to what extent the tooth contributed to the rabbit's death. B 
(Rabbit 1189) died spontaneously in twenty-two days, with a 
loss of 149 grams, or 15 per cent. The tooth was boiled for two 
hours. C was autoclaved at thirty pounds pressure for one hour. 
This rabbit (No. 1171) was chloroformed in six days, as it was 
nearing death, with a loss of 332 grams, or 31 per cent. It is 
therefore apparent that these infected teeth contain a substance 
which has a direct action on metabolism. This rabbit, having 



466 DENTAL INFECTIONS, ORAL AND SYSTEMIC RESEARCHES -VOL. I 




Figure 212. One of several rabbits which developed pneumonia following the implanting of an 
infected tooth. a, pneumonic lung; b, the encysted tooth. 

lost this large amount, was rapidly approaching death; and, in 
order to secure the blood before any postmortem changes could 
take place, it was chloroformed; and while under chloroform 
before death, sufficient blood was aspirated from the heart to 
make our blood calcium determinations. In this rabbit the ionic 
calcium was approximately normal, 10.7, and it, apparently, had 
not undergone the same structural changes of the blood that those 
rabbits did which had this same tooth planted beneath their 
skins before it was boiled but with its normal infection as taken 
from the patient. 

A further and striking evidence of the toxicity of these infected 
teeth and of the nature and stability of this toxin, is shown in the 
fact that frequently the rabbits carrying these implanted teeth 
die of pneumonia. Such a case is shown in Figure 212. This 



CHAP WW ill NATURE & I I V II IN OF DEN I \i GRANULOMA 167 

rabbit had a tooth planted which had previously killed several 
rabbits by subcutaneous subdermal implantations, hut before 
this implantation it was autoclaved for one hour at thirty pounds. 
1 he rabbit died in thirty-five days and lost in weight 617 grams, 
or 36 per cent. 

It may be argued that in these eases the heating to high tem- 
peratures has produced a protein compound that is irritating or 
poisonous. To test this further we have heated a tooth to 56° for 
one hour. This should not produce structural change in the pro- 
tein molecules sufficient to be toxic, and should destroy non-spore 
touring organisms, which would include the streptococcus. This 
rabbit died in eight days, with fibrous encapsulation, as shown 
in Figure 213. It lost 145 grams, or 16 per cent. 




Figure 213. Tooth wan heated to 56° for one 
hour befork implantation. 

The so-called granuloma, for this seems clearly a misnomer, 
has apparently in these cases destroyed a large number, and in 
some instances a large proportion, of the bacteria present. To 
test this further we have placed pieces of such granuloma taken 
from healthy individuals on agar plates, which had first been 
inoculated by flowing over their surfaces a suspension of bacteria 
and pouring off all excess. As shown in Figure 214, while the or- 
ganisms grew in massive colonies all over the plate, practically no 
organisms grew for several millimeters surrounding the granu- 
loma, notwithstanding the fact that we might readily expect that 
its bacteriolytic action should only be available during the time 
of its vitality. 



468 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




Figure 214. Shows the reduced bacterial growth in the vicinity of 
a well organized granuloma when placed on an infected petri dish. 



SUMMARY AND CONCLUSIONS. 

We would, accordingly, change our interpretation and evalua- 
tion of that structure which Nature builds about a root apex. 
With these data in mind, let us review the findings of Chapter 3 
in which, in many instances, the same infection produces an 
entirely different structural change about a root apex, to what it 
does in others ; and in Chapter 4 that there is a great difference 
in the susceptibility of individuals to injury from dental infec- 
tions; and particularly in Chapter 5 that it is those individuals 
with the large area of rarefaction about the tooth, and hence a 
large so-called granuloma, who prove to be the persons who, as 
shown in Figure 200, have a high defense or are free from danger 



CHAP WW ill NAT1 RE & Fl N< riON OF I >l \ I \i GRAN1 LOMA 169 

from injury from their dental infections. Since, then, (1) these 
large areas, as is continually shown in surgical procedure in re- 
moval of teeth, contain a more abundant defensive membrane, 
which type of membrane Nature reproduces in the rabbit, if thai 
same tooth be placed beneath the skin, and thereby protects the 
rabbit from the toxic substance within the tooth; and (2) since 
the blood changes as expressed in ionic calcium vary in direct 
proportion to the ability to build such a membrane, we find no 
alternative from the following conclusions: ♦ 

1 The so-called granuloma is a misnomer, for it 
is a defensive membrane and not a neoplasm. 

(2) A normally functioning periapical quarantine 
tissue is Nature's effective mechanism for protect- 
ing that individual by destroying the organisms 
and toxins immediately at their source, and there- 
by completely preventing the tissues of that indi- 
vidual's body from exposure to either of these 
agencies. 



CHAPTER XXXIX. 

CHANGES IN THE SUPPORTING STRUCTURES OF THE 
TEETH, DUE TO INFECTION AND IRRITATION 

PROCESSES. 

EXPERIMENTAL AND DISCUSSION. 

In the preceding chapter, the data have disclosed a wide varia- 
tion in the structural changes which occur in the supporting 
structures of the teeth, depending upon the nature and quantity 
of the irritant or infection, and the capacity for defensive reaction 
on the part of the individual. In Chapter 3, we saw that either, 
or both, a rarefying osteitis or a condensing osteitis may be pro- 
duced about the apex of a root of a tooth; and in Chapter 5, we 
found that the condition expressing itself in very extensive de- 
struction of bone about the apex of a root, occurs in individuals 
with a high defensive reaction against the dental infection; that 
in these individuals, during the time of their high defense, the 
zone of rarefaction blends into the medullary spaces in a diffuse 
manner; that when these individuals lose this high defense, the 
zone not only ceases to become larger, but a fistula, if present, 
tends to become closed, and a zone of condensing osteitis tends to 
develop around the zone of rarefaction; and that in those individ- 
uals with a low defense for the type of infection always 
found in dental lesions, streptococcal diplococcal types, not only 
low at present but for a long period previously, the condition 
resembles that of the last type except on a much smaller scale in 
that the zone of rarefaction is usually very much smaller, for a 
given infection, while the zone of condensation may be very much 
greater. 

I have undertaken to discover somewhat more in detail the 
nature of these processes, and in order to do so have made exten- 
sive dissections of a large number of maxillae and mandibles. A 
typical illustration of what we have just reviewed in the preceding 
is shown in Figures 215 and 2 16, which show in 215 a mandible with 
two bicuspids and three molars in place, with the buccal plate 
removed. A couple of metallic wires have been placed through 
the inferior dental canal, passing out through the mental foramen. 

470 




/ 



f 



A 











^- 



Figure 21o. A, the roentgenographs appearance of the dissections in 
B and C. Note pocket between second and third molars and adjoining 

RADIOPACITY. B AND C SHOW THE ARRANGEMENT OF THE CALCIFIED STRUCTURES. 

Figure 216 shows progressive enlargements of the normal and path- 
ological bone about the molar teeth. (Note: In the various views 
of this specimen an artefact presents, seen in Figures 215-B and 

471 



472 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 




Figure 216 Enlargements of preceding to show trabecular arrangement and condensing osteitis 
surrounding a periodontoclasia pocket. a late stage. 










B 

Figure 217. A, osteoclasts in the process of removing alveolar bone i\ perio- 
dontoclasia. B. A cross section of the tooth and supporting alveolar bone. 



473 



474 DENTAL INFECTIONS, ORAL AND SYSTEMIC—RESEARCHES— VOL. I 

216-A. When the tissue was being cleaned the bicuspids were dis- 
lodged and were cemented back without care being taken to have 
them properly seated. What appears to be areas of absorption 
about the apices of the two bicuspids are open spaces due to the 
fact, that the teeth are not receded properly in their sockets. 
There is no pathological absorption; the original lamina dura is 
present.) Several things will be noted: First, the very porous 
condition of the normal bone below the bicuspids and first and 
second molars, and the very dense bone, amounting almost to a 
homogeneous mass, below the second and third molars. A more 
careful examination of this case reveals, as shown in the roent- 
genogram in 215-A, that there is an old periodontoclasia pocket, 
mesial to the third molar, where food was packing; and my inter- 
pretation of the condition would be, that this individual's defense 
had reduced a considerable time before his death; and that with 
this lowered defense, the active spirochete infection in the peri- 
odontoclasia pockets, which had been a participant in the original 
destruction of the gingival crest and alveolar bone, had largely 
given way to coccal infections, particularly streptococcal, in the 
deep tissues, and bacillary forms in the periodontoclasia pockets. 
The effect of the irritation in the vicinity of this bacterial inva- 
sion was entirely different frcm the process that had occurred 
earlier in the history of this lesion. At that time, when the pa- 
tient's defense was high, the cellular activity was so acute that 
with the stimulation of the irritation, all cell function was high. 
With the toxic irritation came a very marked dilatation of the 
capillaries. These poured out their defensive factors, which were 
markedly alkaline and contained large numbers of leucocytes. 
These defensive factors were quite ample to establish a quaran- 
tine about that local infection, thereby inhibiting the passage 
of either the bacteria or their products from entering the system. 
A part of this process involved the destruction of alveolar bone, 
for the fluids and cells poured into this part were those adapted 
for the tearing down of alveolar bone as fast as it became in- 
volved. 

This process of decalcification is so often a physiologic one that 
it is difficult to distinguish between a physiologic and pathologic 
absorption of bone. An illustration of this process is shown in 
Figure 217, which shows in B a cross section of a tooth and the sup- 
porting alveolar bone, and in A the giant cells in the deepest part 
of the periodontoclasia pocket engaged in the process of taking 



v IAP. XXXIX CAUSES OF CHAN iES IN SI PPORTING STRl ( H Rl 

down tlir hard structures and transporting them in an absorpl ion 
process. With the development of overloads, whether age, i 
posure, or disease, the defense of all individuals goes down; and in 
Figure 215, we see a zone of very dense bonr where the trabecular 

structure is almost completely obliterated. If we would compare 
the bone formation about the roots of the first molar with that of 
the second and third molars, we would find a very striking differ- 
ence. This is shown in higher magnification in Figure lilt). Note 
that the lamina dura about the roots of the first molar is the thin 
shell supported lightly by trabecular of small size, which form 
almost a lace-like network in the body of the mandible. Note 
where a section of the cancellous osseous structure is broken out 
below the apex of the distal root of the first molar, that there is an 
open osseous channel exposed, through which the blood vessels 
and nerves entering the distal root of the first molar pass pro- 
tectedly in a tube through the medullary matter up to the root 
apex. This condition is also shown in the osseous structures lead- 
ing to the mesial root of the first molar. 

The roentgenographic study of this condition is shown in A of 
Figure 215. and reveals the following: a zone of condensation or 
radiopacity about the second and third molars and a normal can- 
cellous bone about the first. 

Before proceeding with the discussion of these structural 
changes, I wish to call attention to the fact that, in preceding 
chapters, I have frequently spoken of the fact that teeth and their 
sockets of individuals with normally high defense, and particularly 
those with abnormally high defense, respond very differently 
in the various surgical procedures, operative and postoperative. 
For example, it will readily be seen why it would be very easy to 
infiltrate an anesthetic into the supporting structures of the bi- 
cuspids, while it would be relatively difficult in these molars; and 
also with a highly vascularized medullary fat filling the inter- 
spaces between the trabecular about the bicuspid roots, it would 
be exceedingly easy for Nature both to combat infection and re- 
pair tissue, as compared with her facilities and ease for carrying 
on that function in the case of the molar roots. The vasculariza- 
tion is gone, largely, in the latter case. It would be much more 
difficult to extract a root in this latter condition and it would 
readily be understood why the old process would be very much 
more delayed and interrupted in this latter condition; and, indeed 
it could easily be understood why Nature might desire to throw 



« 




3 



f 







D ** 




3 




i- 

^ 




^w 



Figure 218. A proliferative arthritis in "a rabbit's 

SHOULDER. A. D, AND F SHOW NORMAL SCAPULAE; B, C, AND E 
GROSSLY DEFORMED. 

476 



CHAP. XXXIX CAUSES OF CHANGES IN SUPPORTING STRUCTURE 

oft' as a sequestrum a large or small part of this condensing bone. 

But our process is not limited in this instance to the irritation 

of infection entering the original exposed and necrotic bone, for 
the presence of that infection has, as we have shown in Chapter 8 
on Periodontoclasia and Pulp Involvement, in all probability, 
injured the pulps of these teeth. 

There is another and very important phase of this problem 
which has not received proper consideration, which is the reaction 
of the infection from near or distant parts of the body on the sup- 
porting structures of the teeth. In the preceding discussion, we 
have almost entirely limited our considerations to the effect of 
dental infections on the immediate adjoining dental and support- 
ing structures, and upon other tissues and organs of the body. 
Since a tooth is suspended in a socket in such a manner as to make 
a movable joint, it and its supporting structures are subject to 
many of the structural changes to which any or all joints may be 
susceptible. In order that we may understand, somewhat, the 
nature of this process, we will approach it by a consideration of 
the changes which take place in the joints. These may be, in 
general, divided into two main groups which we will refer to as 
degenerative and proliferative processes. Each of these will pro- 
duce deforming arthritis. In the first there is marked ankylosis, 
lack cf mobility, and with removal of the dental infection or other 
source of irritation which has been largely instrumental in fur- 
nishing the toxic and infective processes for its development, there 
may be a cessation of inflammatory process with fixation, a more 
or less permanent ankylosis, but often with quite complete free- 
dom from pain. These individuals may live for years, not in- 
frequently twenty or thirty, with many or nearly all joints of the 
body immobile. In other instances there is a slow reparative 
process. In the second group, with the degenerative arthritis, 
there tends to be a destruction of synovial membrane, with de- 
struction of the cartilages and often with marked absorption of 
the bone. These two types are shown reproduced in rabbits in 
Figures 218 and 219. It is important to note that in our animal 
studies we have found that strains taken from some teeth tend 
quite regularly to produce in rabbits the former type, while 
strains taken from teeth of other patients inoculated into rabbits 
produce changes of the latter type. We will discuss this in fur- 
ther detail in a later communication. 

A minute study of the pathological changes will be seen in the 



478 DENTAL INFECTIONS, ORAL AND SYSTEMIC -RESEARCHES— VOL. I 




T 




Figure 219. A degenerative arthritis in a rabbit's hip 

JOINT. A, NORMAL HEADS OF FEMORAE; B, DESTRUCTION OF EN- 
TIRE ARTICULATING SURFACE. 

following figures. Figure 220 shows a section through the knee 
joint of a rabbit suffering from acute rheumatic infection result- 
ing from a minute inoculation in the ear vein. It will be noted 
that the inflammatory process has attacked the trabecular struc- 
ture and also the cortical layer beneath the synovial membrane. 
The synovial membrane is itself seriously attacked in some places, 
as shown in Figure 221. It will be observed that the degeneration 
is extending through this membrane into the cortical layer. The 
tissues of the knee shown in Figures 220 and 221, were cultured 
and a diplococcus was isolated which was also shown in direct 



CHAP. XXXIX CA1 SES OF CH UMGES IN M PP1 >R flNG STRU( 1 1 R] 







■ • •- : • • i • •. r - ■ *. . 









*>, 






W 






**.* 






Figure 220. A degenerative process in trabeculae and cortical layer of a rheumatic 

JOINT. 



480 



DENTAL INFECTIONS. ORAL AND SYSTEMIC-RESEARCHES-VOL. I 




Figure 221. Beginning inflammatory process in the synovial membrane. 



CHAP XXXIX ( MJSES OF CHANGES IN SI PPOR1 ING STRUCTURE! 








Figure 222. Diplococci seen in a smear from a rheu- 
matic JOINT. 

smear. These are shown both free and phagocyted in Figure 222. 
Irritations of the peridental membrane which stimulate its cells 
to an osteoclastic reaction may produce changes in any adjacent 
hard structures. Consequently the processes which attack the 
alveolar bone frequently attack the cementum and even the den- 
tin of the tooth. A most striking and interesting illustration of 
this is shown in Figure 223, in which instance a lateral tooth was 
under orthodontic treatment. As shown in 223-A, there was a large 
metallic filling on the lingual surface. Beneath the old metallic 
filling there was infected caries which had not been observed. 
With the addition of a little pressure on the tooth, an acute pulpi- 
tis developed; and since the case involved the movement of the 
cuspid, which was quite entirely outside the arch, it was deemed 
best to extract this lateral thereby to give available space for 
placing the cuspid without a long tedious operation of the move- 
ment of the molars and bicuspids. This gave us a very favorable 
specimen for study, a condition we had been looking for. B shows 
the low power view of a section of this tooth ; and it will be noted 
that on the side receiving the pressure, the cementum is almost 
entirely removed. Attached to this side there were areas of peri- 
dental membrane, as shown in Figure 223-B. Two of these are 



482 DENTAL INFECTIONS, ORAL AND SYSTEMIC RESEARCHES— VOL. I 




Figure 223. A cross section of a tooth under ortho- 
dontic pressure. Note absorption on the advance side of 
movement. 




Figure 224. A. B. and C, osteoclastic activity; D, hemorrhage into pulp of tooth of previous figure. 

483 



484 DENTAL INFECTIONS. ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

shown in Figure 224- A and B, in which it will be observed that the 
cementum has been entirely removed in places and the process 
is proceeding into the dentin. The osteoclastic cells are clearly 
shewn in the process of removing this structure. Itis also impor- 
tant to note that this process has extended in some places deep 
into the dentin. A section across one of these burrowing excava- 
tions is shown in Figure 224-C. Either due to the toxic materials 
from the caries or to the mechanical trauma of the orthodontic 
process, or both, there was developed, as previously stated, an 
acute pulpitis. It is exceedingly interesting to note that there 
were profuse hemorrhages into the pulp tissue which, apparently, 
had previously been undergoing a process of fibrosis. This is 
shown in Figure 224-D. 

When we study clinically some of our patients who have had 
deforming arthritis for years, we find that not only is there evi- 
dence of the most indisputable type that the dental infections 
have contributed directly to the development of the arthritis, but 
there is just as indisputable evidence that some of these individ- 
uals have had characteristic degenerative processes produced in 
their teeth, which were not otherwise involved, by their general 
rheumatic condition. In the former of these two conditions, one 
of the forms that the evidence takes is that individuals who have 
suffered for years from acute or subacute processes, have had 
complete and continued relief from the recurring exacerbations, 
and a change of their general state from one that had been getting 
progressively worse to one that became progressively better; and 
this same history had repeated itself in the same individuals 
by the subsequent involvement of other teeth, followed by a 
return of their acute processes, all tending to a return toward 
normal with removal of the dental infections. But note, 
in these cases these changes, which developed following the 
involvement of new teeth, were related to a primary injury to 
the tooth in the form of deep caries involving the pulp, which 
developed in the regular sequence, periapical involvement, and 
degeneration and irritation of the supporting structures. In the 
latter of these two conditions — namely, where the arthritis pro- 
duces injury and degenerative processes in the teeth — we have 
found these degenerative changes, first in the peridental mem- 
brane, and then in the pulp, without the approach of caries or any 
apparent evidence such as will ordinarily be found requisite to 
produce a destruction or change in the dental pulp. To cite a 



CHAP XXXIX ( \l SES OF CHANGES IN SUPPORTING STRU< 1 1 RES 185 

specific case, one of the arthritic cases that I am watching very 
closely lias in five years had six teeth come to have non-vital 
pulps, or definitely involved and infected pulps, without the ap- 
proach of dental caries; and in every instance after the removal of 
these teeth, the patient experienced distinct, and marked improve- 
ment. This is a matter of extreme importance, for if the teeth 
may become involved as a result of the systemic rheumatism, as 
well as be an important causative factor, it will throw an entirely 
new light upon cur responsibility in the care of arthritic cases. 
But this is so important a matter that I will make it a separate 
study in the next chapter. 

SUMMARY AND CONCLUSIONS. 
Characteristic localized structural changes de- 
velop in the supporting structures of teeth when 
the latter carry infection within their structures. 
These changes are, however, determined chiefly by 
the host and are an expression of the reacting 
characteristics of the host rather than an expression 
of the invading bacterium. 



CHAPTER XL. 
DENTAL INVOLVEMENTS CAUSED BY ARTHRITIS. 

PROBLEM: Can arthritic injections of the body attack 
and devitalize the teeth? 

EXPERIMENTAL AND DISCUSSION. 

It has been presumed that the teeth are only subject to the 
diseases which may be directly caused from the entering in and 
around them of infection. Some years ago I noted in my records 
that all the bones of patients having arthritis of a certain type 
tended to be more dense than normal, while other types of ar- 
thritis tended to have little condensation, and in some instances 
definite reduction in the calcification. By studying the maxillae 
in mandibles of these patients we have found that the medullary 
spaces were very much smaller and the trabecular formed a very 
much larger percentage of the body of the cancellous bone 
in patients with arthritis. It often took the form that resembled 
a quite uniform condensing osteitis throughout the entire mandi- 
ble or maxilla. 

One of these cases I have been studying for twenty-five years. 
In 1901 I roentgenographed her teeth and found that a filling 
in an upper right bicuspid, that had been put in years previously, 
did not extend to the apex, and proceeded thoroughly to sterilize 
and correctly to root fill it, for the teaching of that time was more 
confident than the teaching of today, that dental infections could 
be readily destroyed by any one of many forms of medication, if 
properly applied. As shown in my roentgenogram taken in 1901, 
there was definite apical absorption with a concentric arrange- 
ment of the trabecular about the apex, which I now take to indi- 
cate a series of exacerbations and reactions with condensation on 
a part of the inflammatory process. After this tooth was, as I 
suppcsed, perfectly sterilized and root-filled, I had what I prob- 
ably showed, as many others are doing today, what I supposed to 
be evidence of my remarkable skill in sterilizing this tooth and 
making it safe for this patient ; for, as shown in B of Figure 225, 
the apical area of absorption filled in, and from this indisputable 
evidence the infection had been all destroyed, which fact was also 

486 



CHAP XI DENTA] INVOLVEMENTS CAUSED B^ ARTHRITIS 487 




Figure 225. Progressive development of radiopacity of second bicuspid oi 
patient with deforming arthritis. a. in year 1901; b, 1914; c, l916. 

guaranteed by the symptom that the tooth was not in the least 
sore, and comfort endorsed the guarantee. But at the time I did 
this, this patient already had deforming arthritis following a 
severe attack of rheumatism, which had been so severe that her 
hands were already deformed and becoming rigid. Her ankles 
were also slightly involved. During the years from 1901 to 1916 I 
saw her occasionally, made dental repairs, and, as my researches 
progressed, I finally became very much alarmed and conscience 
stricken for fear the fact, that she was getting progressively and 
seriously worse, might be due in some part to my mistaken inter- 
pretation of the assurances of the success of my operations. I, 
accordingly, sent for her, at which time she was so nearly immo- 
bile that she practically had to be carried to the office. With the 
removal of these two teeth, with the condition as shown in Figure 
225-C, she made a very definite and marked improvement. 

But at the time of their removal I took great care to study her 
case in further detail. I undertook to remove the teeth without 
the possibility of the mouth infection's contaminating the roots, 
which was accomplished by using the actual electric cautery with 
which I seared the anesthetized tissue deep into the alveolar bone 
surrounding the necks of these teeth. Upon their extraction, I 
drilled into the apices and found both these bicuspids infected. 
( This matter of drilling into extracted teeth after sterilizing the 
surface, and culturing the chips has been done very many times 
in the last six years, and practically without exception I have 
found the teeth which I was testing to be infected.) But, in addi- 
tion, I drilled into the bone a quarter of an inch beyond the apex 
and found the same strain of streptococcal infection in the bone. 
Three months later, under local anesthetic and actual cauterv to 



488 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

sterilize the surface, I again drilled into the periapical bone and 
found it still infected with this same strain. These findings, 
together with the fact that this patient who had been growing 
progressively worse, had now become progressively better, not 
only put me in a new attitude regarding her teeth, but put her in 
a state of such positive conviction regarding the relation of her 
teeth to her health that, from that time to the present, she has 
persistently urged that I extract all her remaining teeth. My 
attitude has been to be ready to extract any teeth that I thought 
might be doing her more harm than good, but since she could 
only put one hand to her mouth to remove a denture and would 
therefore, if she got much worse, be in a position where she could 
not handle artificial teeth, it seemed very desirable to retain such 
teeth as were definitely free from involvement and not subject to 
the possibility of contributing to her dental condition. Since 
that time, as stated above, six teeth, one after another, have be- 
come involved, (as evidenced by the symptoms which I will 
presently recite), and have one after another been extracted, 
after each of which extractions she has expressed a confidence 
that she felt definitely better. When asked how she knew, the 
reason she recently gave was that she had again become able to 
sew, a thing that had not been possible for years. 

Just here I wish to introduce a warning : Exodontists and phy- 
sicians who do not have the heart rending worries of making den- 
tures comfortable and serviceable under conditions which are so 
nearly impossible as to very discouraging, but where the very 
nutrition of the patient demands a persistent effort, will be dis- 
posed to take the evidence just cited as justifying the extraction 
of all the teeth for this and similar patients. I wish to stress that 
we have come to the time when involved teeth can be so definitely 
differentiated from those that are not involved, or with sufficient 
limit of error, that we are not justified in condemning all of the 
teeth for fear they may be involved. I am seeing continually, 
patients who are suffering more from the inconvenience and diffi- 
culties of mastication and nourishment than they did from the 
lesions from which their physician or dentist had sought to give 
them relief. 

In Figure 226 I have shown in a series, A to G, the six teeth that 
have been extracted since the above experience, one or two a year; 
and some interesting and important data have been accumulated 
regarding their conditions. In the preceding chapter, I have 




FIGURE 22b. SIX TEICTII WHICH BECAME NON-VITAL IN SUCCESSION IN THE MOUTH OK A PATIENT WITH DEFORM- 
ING ARTHRITIS. 








J» 




\ 



Figure 227. Osteoclastic absorption of tooth structures and calcification ok pulp in a patient 
with depormlng arthritis. 



489 



190 DENTAL INFECTIONS, ORAL AND SYSTEMIC -RESEARCHES-VOL. I 




Figure 228. Absorption of cementum and dentin as part of arthritic disease 
of tooth shown in Figure 227. 

shown in Figure 217 a histological section of the process of bone 
absorption, in which the giant cells are busy carrying away the 
bone structure. In Figures 220 and 221 1 have shown some of the 
process of joint degeneration in the earliest stages of arthritis, and 
in Figures 218 and 219 I have shown illustrations of two types of 
rheumatic arthritis, one degenerative and the other proliferative, 
as evidenced by the marked depositions of the bones involved 
in Figure 218-B, C, and E, and the destruction and absorption of 
the head of femur in 219-B. 

With these processes in mind, let us study the histological 
changes that have been taking place about the teeth of this pa- 
tient as they have become involved. In Figure 227 we have a cross 
section of an upper left molar which had developed symptoms 
which made me suspicious that it was degenerating. The begin- 
ning of calcification of the pulp of one of the roots is shown. But 
more important for this immediate consideration is the process of 
absorption taking place upon the surface of the root, for it will be 
seen that an inflammatory irritation is in progress, which has 
destroyed the cementum of a considerable area and is penetrating 
far into the dentin. Figure 228 shows a larger view of this process, 
and it will be seen that this structure is highly vascularized and is 




Figure 229. Osteoclastic activity, high power, of Figure 228. 



abundantly filled with a special type of cells and that it is burrow- 
ing deeply into the dentin. A still higher magnification of this 
condition is shown in Figure 229, in which it will be seen that these 
giant cells are very abundant. Some are in close contact with the 
dentin; others are migrating. We have in this process a reaction 
very similar to that taking place in degenerative arthritis of 
joints. This is distinctly shown in Figure 230, which is a histologi- 
cal section of an acute inflammatory process produced in the joint 
of a rabbit by the inoculation of a strain producing arthritis; and it 
will be noted that the process is almost identical with that we have 
taking place about this tooth. 

If we would refer again to Figure 227, we will note the beginning 
of decalcification of this pulp. Figure 231 shows a higher magnifica- 
tion of this, and it will be noted that the zones of calcification tend 
to develop around blood vessels and in the odontoblastic layer. 
The pulp tissue has largely lost its original structure. Fibrous 
bands are forming beneath the odontoblastic layer and around 
the blood vessels, and these in turn are becoming calcified. In 
other illustrations, we have shown lamination of pulp depositions 
by the successive layers becoming calcified. This process may go 

491 



492 DENTAL INFECTIONS, ORAL AND SYSTEMIC -RESEARCHES— VOL. I 
( 









>J 







31 




Figure 230. Osteoclastic reaction produced by rabbit: A. in an arthritic joint: B. in an 

IMPLANTED AND ENCYSTED TOOTH. 

on until the pulp has been very largely, or practically completely, 
obliterated by calcification. This is illustrated by one of the 
teeth extracted from this patient, a cross section of the root of 
which is shown in Figure 232. When the roots were cut from this 
tooth at the crown, it was found that not only were both roots 
completely calcified, but the entire coronale part of the pulp cham- 
ber was filled with a closely fitting casting. One huge pulp stone 
had apparently come to fill the entire pulp chamber. By referring 
to the roentgenogram of this tooth, shown in Figure 233, it will be 
noted that there was no evidence of root canals or of pulp cham- 
ber. This latter fact should be considered very important, as 
will be shown in the diagnosis of this condition. 

A very important factor regarding this tooth (the upper right 
first molar) was the following : that notwithstanding this extreme 
and apparently complete calcification of the pulp, the tooth was 
not only hypersensitive to hot and cold, but was sensitive to irri- 
tation of the exposed dentin to instrumentation. The patient 
complained that she would be awakened in the night by the pain 
in this tooth resulting from her mouth's opening when she was 
asleep, and the cold air chilling the tooth would produce so violent 



CHAP. XL DENTAL INVOLVEMENTS CAUSED B'b XKIIIKlll^ 193 




Figure 231. Calcifications i\ the pulp of tooth shown in Figure 227. 




Figure 232. Cross-section of a decalcified pulp from a patient with arthritis. 



494 DENTAL INFECTIONS. ORAL AND SYSTEMIC— RESEARCHES— VOL. I 



Figure 233. Roentgenographic ap- 
pearance OF TOOTH WITH COMPLETELY DE- 
CALCIFIED pulp, shown in Figure 232. 




a toothache that it would waken her. After her mouth had been 
closed a sufficient length of time, the tooth would become warm 
and the pain would cease, all this to be repeated if she continued 
to sleep in a cold room, for she could lie only on her back, in which 
position the mouth tends so readily to open. 

With regard to the matter of diagnosing these teeth, those teeth 
which have become involved have passed through the following 
progressive history. There would be symptoms of tenderness or 
irritability such that she would want to make pressure on them, 
or they would be tender to pressure, not acute as develops from 
pericementitis from an infected pulp. This stage was followed 
by one of hypersensitiveness to heat and cold. In two of the 
teeth where she did not heed these symptoms promptly enough, 
the two lower incisors, the pulps became non-vital and non-re- 
sponsive to thermal change. Two or three times a year we care- 
fully go over the remaining teeth of this patient and test each 
tooth in succession for normality to reaction to thermal change, 
to history of tenderness and the roentgenographic appearance of 
the pulp. On extraction, these teeth frequently show either 
macroscopically or microscopically on the surface of the cemen- 
tum evidence of the arthritic process. This may be illustrated 
in low power or macroscopically by either a roughened condition 
of the cementum or the attachment to the cementum of little 
fibres by the frayed ends of the frayed attachments of the sup- 
porting fibres which have not torn loose from the tooth but have 
been broken midway, one end remaining attached to the alveolus, 
and the other attached to the cementum. Another condition 
which frequently occurs is shown in Figure 234, in which it will be 
seen on the mesiobuccal root that there is at one point a deep 
pitting of the cementum and dentin by an absorption process, and 
close by a nodule of proliferative deposition of osteoid tissue upon 
the cementum. 





Vs 



\- . 



J | 






I 



) 





Figure 234. Arthritic changes in external surfaces of tooth with calcified pulp from arthritic 



PATIENT. 



495 



496 DENTAL INFECTIONS, ORAL AND SYSTEMIC-RESEARCHES— VOL. I 




Figure 23o. Arthritic hypertrophic nodule on root. 




Figlre 236. Cross- section of hypertrophic nodule, shown in Figure 235. 



The distobuccal root of this same tooth had even a larger ar- 
thritic nodule built upon it, shown in Figures 235 and 236. The 
mesiobuccal root is shown in the cut in Figure 234. A shows 
roentgenograms of the two buccal roots of the extracted tooth 
and separately of the palatal root and of a small section cut from 
the palatal root to illustrate how completely the pulp chamber 
was calcified. B shows this deeply burrowed pit with the built up 
nodule of osteoid tissue. C and D show these two structures in 




FIGURE 237. Skin lesion OF RABBIT WHICH LOST 28 PER cent in weight in twenty-two 

DAYS, PROM IMPLANTATION OF CALCIFIED ROOT FROM ARTHRITIC PATIENT. 

cross section and higher magnifications, and it is of interest to 
note that the nodule is bridged over an open'space, or, as it were, 
a cavern in the dentin with two other caverns shown deeper in the 
dentin. 

When we remember that this tooth was not only responsive to 
thermal changes but was really hypersensitive and painful, show- 
ing a clearly exalted vital response, we would naturally not look 
upon it as being infected structure. The palatal root, therefore, 
when it was cut from the freshly extracted tooth, was immediately 
planted beneath the skin of a rabbit to determine whether it was 
an infected structure capable of doing the animal injury. A sec- 
tion of the tooth was also cultured. The rabbit shown in Figure 
237, under the skin of which was planted the palatal root of the 
tooth we have been reviewing, died in twenty-two days, having 
lost 295 grams, or 28 per cent of its weight, or nearly \)/ 2 per cent 
per day. 

Returning to the discussion and study of the pathology of the 
pulp, some very interesting features had developed. As stated 
previously, not only was the pulp tissue of the roots entirely calci- 
fied, but also the bulbous portion. High power magnifications of 
this pulp tissue are shown in Figure 238. In A will be seen channels 
through which the blood vessels passed, and around which the 
calcifications developed. In B will be seen what appears very 

497 




Figure 238. High magnifications of sections of calcified pulp. Note 
dentin-like structure in b. 

498 



CHAP. XL DENTA1 INVOLVEMENTS CAUSED B} \\i \\:\i\\ \^ 



199 




Figure 239. Section of alveolar bone fused into a root following an inflammatory reaction. 



similar to dental tubuli. But these are not in dentin; they are 
in this osteoid structure radiating from one of these blood vessel 
chambers which is shown in the lower part of the field. They do 
not, in this view show an intercommunicating system of connect- 
ing channels, each appearing to be dependent throughout its 
course. We have frequently found these in calcified pulps, and it 
is not impossible that they are in some way related to, either in 
origin or in structural type, the dentinal fibres of the odonto- 
blasts. 

It frequently occurs that this degenerative process subsides, 
or there is a reversal so that an absorption process is transferred 
into a proliferative one, and this same tissue, which up to the 
time of the change in systemic conditions was engaged in the 
tearing down of osseous and dental structures, proceeds to fill up 
the chambers it has burrowed out with a new structure. Of 
course, it cannot reconstruct dentin or cementum, not having 
either odontoblasts or cementoblasts; but it does have osteoblasts. 
It, accordingly, builds an osteoid structure, sometimes with an 
haversian system very closely resembling true bone. This con- 



500 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

stitutes what we have discussed as a condition of ankylosis. This 
is typically illustrated in Figure 239, in which instance, when I 
extracted the tooth, I found it necessary to chisel off every little 
piece, there being no clearly defined zone of cleavage between the 
tooth structure and the alveolus. 

SUMMARY AND CONCLUSIONS. 

( 1) It will be seen from these data that a systemic 
involvement of multiple arthritis may, while at- 
tacking various joints of the body, also attack those 
of the joints of the teeth; and, further, that this 
process of inflammation with degenerative and pro- 
liferative processes may cause the involvement and 
ultimate death of the pulp. 

(2) The involvement of these teeth as a result of 
the progressive systemic arthritis may in turn, and 
doubtless frequently, if not generally, does aggra- 
vate the general condition, for the tooth structure, 
when it becomes infected, is even less capable of 
vascularization and therefore less amenable to the 
processes of defense, than is bone. This stresses the 
very great importance that, individuals having de- 
forming arthritis, shall have most careful dental in- 
spection and care, and also, since it is one of the 
most horrible of living deaths, every effort should be 
made to prevent the beginning of that process; and 
since the evidence is so overwhelmingly that the 
initial infection frequently, if not generally, comes 
from the teeth, helpless humanity deserves pity 
until the powers that be shall make a worthy effort 
to find the means that will prevent this needless 
catastrophe in so many lives. 



CHAPTER XLI. 

VARIATIONS IX THE DEFENSIVE FACTORS OF THE 

BLOOD. 

PROBLEM: Is there a difference in the defensive factors 

of the blood of susceptible and non-susceptible individuals 
to systemic involvements from dental infections? 

In the preceding chapters, the data secured from the researches 
seemed to demonstrate the following: 

In Chapter 3 we found that the same dental infection expresses 
itself quite differently, locally, in the supporting structures about 
the teeth in different individuals. 

In Chapter 4 there is a very marked variation in the suscepti- 
bility to systemic involvement of different individuals, which 
susceptibility tends to be a family characteristic. 

In Chapter 5 we found that these characteristics of both the 
local and systemic expressions are definitely related each to the 
ether. 

In Chapter 20 on Blood Calcium we found a definite relation- 
ship between the calcium content of the blood in different types 
of individuals, which had been grouped in accordance both with 
their type of local oral pathology and systemic susceptibility. 

In various other chapters we found characterizations and 
relationships which were distinct, as, for example, the relation- 
ship to dental caries, periodontoclasia, rarefying and condensing 
osteitis, etc., etc. 

In Chapter 38 the evidence seemed to demonstrate that the 
so-called dental granuloma is a physiologically acting tissue and 
not necessarily a degenerative type of tissue, though it may be- 
come such with a loss of function of that tissue; and that tissue, 
when taken from an individual with high defense, as judged from 
the fact that he was not having any apparent systemic expres- 
sion from involved dental infections, would, when placed on or 
in infected culture media, show a marked inhibitive power on 
bacterial growth as well as produce a bacteriolysis. 

In Chapter 20 we found that when an infected tooth is placed 

501 



502 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES -VOL. I 




Figure 240. The migration of leucocytes into a glass tube, a chemotactic reaction 
with toxin. 



CHAP. XI 1 VARIATIONS IN rill-: DEFENSI\ E FAC ["ORSOF I HE BLOOD 503 

beneath the skin of a rabbit, either the rabbit builds such a de- 
fensive membrane i in which case it is not seriously injured, or at 
least not promptly so), or else the rabbit's defense is rapidly 

lowered and it dies in a lew days; and in that chapter as in pre- 
ceding chapters, we found that the placing of such a tooth under 
the rabbit's skin produced changes in the rabbit's blood, par- 
ticularly in the blood calcium, and that its prostration was largely 
in direct proportion to depression of the ionic calcium and the 
production of a pathologically combined calcium. 

In Chapter '20 we found that the placing of an infected tooth 
in the blood serum of a patient or animal tended to reduce the 
ionic calcium of the serum and produce a pathologically com- 
bined calcium, and that this condition was apparently identical, 
whether it developed in vitro or in vivo. 

If, then, the dental infection acts directly upon the defensive 
forces of the circulating blood, it should be possible to measure 
and determine these, or at least it would be of very great ad- 
vantage if this can be done. To determine this, we have made 
the following special studies. For some time we have been 
studying the action of the leucocytes in the presence of various 
types of irritants and chemicals. It is most significant, as has 
been shown by others, that when a capillary glass tube contain- 
ing bacteria, dead or alive, is placed beneath the skin of a rabbit, 
the leucocytes tend to be attracted by chemotaxis to these bac- 
terial products and migrate rather rapidly into the glass tube. 
Such a condition is shown in Figure 240. In order to determine 
the depressing effect on the quality of chemotaxis, I have placed 
tubes containing cultures grown from dental infections beneath 
the skins of normal rabbits and have noted the distance into the 
tubes that the leucocytes would travel in a given time. It was 
found that the leucocytes migrated in large numbers to a con- 
siderable distance within the tube. One end of the tube was 
sealed, the open end filled with the infected culture media being 
in direct contact with the subcutaneous tissue as the end of the 
tube was slipped under the skin. When a similar tube was 
placed under the skin of a rabbit, into which a tooth had been 
planted a few days previously and for which the rabbit had 
sufficient defense to build an encapsulation without the produc- 
tion of pus or evidence of other local irritation, it was found 



504 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

that the tube placed not within, but in the vicinity of this cyst, 
had a very much less profuse migration of the leucocytes than 
did the normal rabbit. When we placed a tube under the skin 
of a rabbit which was not showing such good reaction to the 
tooth, for pus was developing and the animal was rapidly losing 
in weight, the tooth having been planted several days previ- 
ously, it was found that the organisms did not penetrate so far 
nor so rapidly as in the normal tissue. 

When we undertake to relate these data — namely, that the 
defense of the rabbits is not only measurable in quantitative 
terms by a study of the chemistry of the blood, but in the physi- 
cal expressions of the leucocytes themselves — we find what seems 
to be a very direct placing of the responsibility for a large part of 
the mechanism of defense upon the leucocytes. In order to study 
this more exactly, I have made the following important experi- 
ments: The blood has been taken from normal animals and 
humans and its power to kill streptococci taken from teeth 
determined both with regard to quantity of organisms and the 
time necessary to destroy them, by placing the live organisms of 
a known number in the freshly drawn blood, with or without 
defibrination, for different periods of time, varying from one 
minute to sixty minutes; and since the number of live organisms 
was known with quite close approximation to exactness by count- 
ing and carefully measured diminutions, it became possible to test 
not only the capacity of the blood for reacting in the devitalizing 
of the live organisms, but to establish the rapidity of this process. 
It has been most striking and unexpected to find that the blood 
of normal healthy animals and normal individuals with a high 
defense will not only kill these organisms in very large numbers, 
but that it will do so in one minute's time, for the difference be- 
tween the effect of leaving the organisms one hour or ten minutes 
leaves so little advantage in favor of the longer time that nearly 
the maximum devitalizing effect has occurred in ten minutes, 
and, indeed, in many bloods this process is almost as efficient in 
one minute as in one hour. Contrary to our expectation and the 
current teaching regarding the mechanisms of defense, which 
have provided that the leucocytes engulf and phagocyte the bac- 
teria, we have found that in this devitalizing process very few of 
the organisms, or at least a very small percentage, have been 
engulfed; by far the great majority have been devitalized; and if 
the blood stains are not examined within a few minutes, the 



Ul \r Ml \ VRIATIONS IN I III DEFENSIVE FA( fORSOF fHE BLOOD 505 




Figure 241. A comparison of a drop of blood from a defective 

PATIENT— A. WITH A NORMAL PATIENT — H. NOTE THE CLEAR ZONE IN B, 
INHIBITING BACTERIAL GROWTH. 

organisms will not only be devitalized, but will be digested by 
special enzymes provided by the blood. 

Before taking up a detailed study of the relation of time and 
the different bloods in this devitalizing process, I wish to review 
experiments made by placing drops of various bloods on infected 
agar plates. Figure 241-A shows one drop of blood taken from a 
patient with a chronically low defense to streptococcal infection, 
suffering from xerostomia and rheumatism, and two drops of my 
blood in B. It will be noted that the organisms not only do not 
grow in or under the drops of my blood, but there is a zone for a 
considerable distance around my blood where this inhibition has 
been complete; whereas, in this patient's blood the zone is very 
diffuse and but slightly marked, and the organisms are growing 
under and over the blood. There is clearly a very great difference 
in the bactericidal property of these two individuals. 

Important new data have been added to the available knowl- 
edge regarding the defensive factors of the blood by Sir Almroth 



506 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

Wright. In the bibliography I have given references to several of 
his contributions. His original work on the determination of the 
cpsonic index of the leucocytes started a new interest in these 
structures. During the war he made important observations 
regarding the defensive factors which are localized in individual 
wounds, such, for example, as the finding, that some wounds of a 
given patient had not only rid themselves of infection, but would 
destroy organisms that were abundant in another wound of the 
same patient when the dressing from the latter wound was placed 
on the healing wound, thus shewing that the defensive factor 
was in part, at least, a local tissue reaction quality. 




Figure 242. 



BCD 

Studies of bactericidal property of blood, one minute exposure. 



In order to establish more exactly this quality of defense of 
different groups, I have made an extended series of platings, in 
which I have used the blood of the patients under study, in com- 
parison with normal controls, to establish, if possible, the nature 
of the variations. In Figure 242 will be seen four Petri dishes. A is 
a control and contains approximately five hundred organisms 
placed in the agar of the Petri dish. B shows the result of taking 
a cubic centimeter of blood from a normal rabbit and placing 
these living organisms in this normal rabbit's blood for one 
minute. The infected blood was then placed in the agar, and it 
will be noted that the five hundred organisms were reduced to 
about fifty. A similar quantity of the counted culture was 
placed in a similar quantity of blood of a rabbit that had been 
infected by placing a tooth under its skin, shown in C. It will be 
noted that a large number of colonies grew out, that the infected 
rabbit was not able to devitalize as many of the bacteria in one 
minute's time as did the normal rabbit. D shows the effect of 
taking some of the blood from a patient whose defense has been 
lowered and who was suffering from rheumatic symptoms. It 
will be noted that while he killed more of the organisms than did 



t. II \r \l l VARIATU »NS IN THE DEFENSI\ E 1 Si n >RS OF rHE BLOOD J 

the mu cted rabbit . he did not kill nearly so many as did the nor- 
mal rabbit. 

When, however, we compare the effect of using a large number 
of organisms instead of five hundred, even though the organisms 
are exposed to the blood for sixty minutes, we find a very differ- 
ent reaction. The result of this is shown inFigure243. Thecon- 
trols, shown in A-l and A-2, show respectively five thousand and 
fifty thousand organisms in the agar plates. The normal rabbit 
was able to kill nearly all of the five thousand and a very large 




Figure 2 !3. Comparison of bactericidal property of blood of a normal and an infected rabbit. 

percentage of the fifty thousand, as shown in B-l and B-2. The 
infected rabbit did not do so well as the normal rabbit, but 
showed a good reacting power. (See C-l and C-2.) The rheu- 
matic patient, however, did net do nearly as well as either the 
normal or the infected rabbit, shown in D-l and D-2. 

Another illustration of the difference in the bactericidal prop- 
erty of the blood of a patient with recurring attacks of rheumatic 
disturbances is shown in Figure 244, which gives two different dilu- 
tions of organisms in A, one marked 8x and the other 65x, where 
x is supposed to be a number approximately a thousand. When 
this quantity, approximately eight thousand, was placed in one 
cubic centimeter of my blood for ten minutes, the reduction in 
growth was reduced from that shown in A to that shown in B, the 
reduction being very great in both the eight thousand and the 



508 DENTAL INFECTIONS, ORAL AND SYSTEMIC -RESEARCHES— VOL. I 




65x 



ABC 

Figure 244. Comparisons of bloods of two individuals. 

sixty-five thousand quantities of organisms. When these same 
quantities of the living organisms were placed in one cubic centi- 
meter of the blood of this rheumatic patient for ten minutes, 
there was a reduction in the tctal number of organisms, as shown 
in C, but the reduction was not nearly so great as it was in the 
case of my blood. 

At this point it would be well, perhaps, for me to make an 
explanation of the appearance of the Petri dishes. Bacterial 
cells, like plants, cannot grow normally if in too crowded a 
location. Consequently, in heavily inoculated Petri dishes the 
cultures are very small, each colony reserving about it an elbow 
room, so to speak; or rather, each takes from the soil nutrient 
material and gives off toxic material. Therefore the colonies 
tend to keep their individuality as units rather than coalescing; 
and the fewer organisms there are to grow in the space, the larger 
the colonies grow, just as a single tree will grow large with wide 
spreading branches, while crowded trees do not do this. 

In Figure 241, 1 showed the difference in the bactericidal power 
of the blood of a rheumatic patient as compared with my own as 
normal, and called attention to the fact, that there was a zone of 
inhibition for a considerable distance around the blood on the 



CHAP Ml \ VRIATIONS IN nil DEFENSIVE FA( fORSOF Mil BLOOD 




Fll.l'RE 24o. A blood with a high defense from a patient recovered 

FROM SYSTEMIC INVOLVEMENT. 

infected agar plate. When such a patient has had infected teeth 
removed, which were apparently very materially disturbing the 
defensive factors, there is a marked improvement in this defen- 
sive quality cf the blood, as shown by these various tests. Figure 
245 shows such a case. This patient has returned to a vigorous 
normal health after having been ill for three years with symptoms 
variously interpreted as heart, digestive, and nervous system 
involvements. It will be seen here that his blood has now (three 
months after the removal cf his infected teeth, during which 
time he has made a very rapid return to normal) become very 
highly defensive. 

That infected teeth produce important changes in the blood 
can be shown in many ways. I have, in the preceding chapters, 
demonstrated their influence on the ionic calcium of the blood, 
the development of leucopenia, erythropenia, leucocytosis, etc.; 
and in Chapter 19, I illustrated the direct effect of the infection, 
whether injected or whether a tooth was planted beneath the 



510 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

skin of a rabbit, in reducing the hemoglobin. In this connection 
let me refer particularly to the experiments in Chapter 20 on 
Chemical Changes in the Blood, in which I showed that the 
placing of an infected tooth in either the blood of a patient or in 
normal blood tended to produce changes directly in the blood 
chemistry. 

In order to determine, if possible, whether the tooth toxins 
tend to produce an hemolysis, I have placed extracts of infected 
teeth with blood and have also made comparisons of the effect 
of placing droplets of the blood, so exposed, on infected Petri 
dishes for comparison with normal blood or the same blood 
before exposed to the infected tooth. This is very excellently 
demonstrated in the colored plate in Figure 246, which shows in A 
three drops of normal blood placed on an infected agar plate; B, 
a similarly infected plate on which have been placed four drops 
of a patient's blood who was suffering from nervous breakdown 
and neuritis. It will immediately be seen that the organisms 
have grown well on and over the blood of the suffering patient, 
whereas the normal individual has greatly inhibited the growth 
on the infected plates. In C we have two drops of the patient's 
blood placed on a similar plate, but before doing so the blood was 
exposed to broken chips of this patient's own infected tooth, 
with the remarkable result that all the erythrocytes, practically, 
have been hemolyzed and the coloring matter has disappeared 
almost entirely from the droplets and is in solution in the free 
moisture in the margins of the dish. All of this suggests, if it 
does not demonstrate, that these teeth contain substances which 
have a very marked influence on the blood of the patient. 

Another important study has been to determine the nature of 
the response that is called forth in the blood by the tooth toxin 
as compared with the bacteria from the tooth. To determine 
this we have vaccinated the drawn blood from rabbits and pa- 
tients with dead organisms, to determine to what extent the 
blood was able to respond to increased attacking power; for, as 
Wright has shown, the defensive elements of the blood cannot be 
estimated, or, at least, are not indicated by the primary response 
to a bacterial invasion that is not great enough to call forth the 
greatest activity. I have, accordingly, taken the blood and 
subjected it to dead organisms of the kind that the media would 
later be inoculated with, and, after holding this vaccinated 
blood, containing a given amount of dead organisms, for from 




Figure 246. Bactericidal properties of bloods: 

a. normal human; b. broken defense; c. broken 

defense plus tooth toxin. 

[chap. xli variations in the defensive factors (if the blood.] 

511 



CHAP. XL] VARIATIONS IN THE DEFENSE E FAC ["ORSOF nil BLOOD 513 

ten to thirty minutes, the Living organisms were then placed in it 
for given periods of time; and it is quite remarkable that many 
individuals show a greatly increased activity of their blood from 
the presence in the blood of a small quantity of the tooth toxin 
prior to, if only for a lew minutes, the placing in the blood of the 
living organisms for ten minutes. The bloods of some other 
individuals, however, make a very little response from the tooth 
toxin as an increased activity or efficiency. There is also a 
quant it y factor. If the blood receives so small a quantity of the 
toxin as would be transferred to it by placing the tips of the roots 
of a freshly extracted tooth into the blood for ten minutes, a 
blood with a good reacting power will show a distinct improve- 
ment over the blood without that exposure to the tooth toxin. 
If, however, the blood is subjected to a considerable quantity of 
this toxic substance, such as putting the crushed pieces of tooth 
into the blood for an hour, it frequently practically paralyzes this 
reacting power, and the growth is many times more profuse than 
if a smaller quantity is used. 

When the sterile, defibrinated, freshly drawn blood has placed 
in it some of the dead organisms, as stated above, their presence 
in the blood furnishes a chemical which acts directly upon the 
leucocytes, which quickly give off, as a result of this chemotactic 
reaction a bactericidal substance of very great power but which 
is not yielded to the blood until the stimulus is offered from the 
living or dead organisms, and either will accomplish the purpose. 
There is, therefore, an amount of dead organisms which will be 
most efficient for a given blood to induce it to its maximum 
bactericidal reaction. 

In Chapters 3, 4, and 5, the results of the researches have 
indicated that there is a very distinct difference in the local 
structural changes in the mouth about dental infections, in 
patients having a low defense, from the reaction which occurs in 
the mouths of patients with a high defense. I have desired, 
therefore, to check carefully these different groups to see whether 
there is a distinct difference in the bactericidal properties of their 
bloods. It is necessary to keep in mind that, while all individuals 
may tend to have a mien, they may depart quite considerably 
from that mien. I have, accordingly, selected two patients on the 
same day, one presenting for prophylactic care. During his life 
he has had exceedingly little caries. The roentgenograms of his 




il4 



CHAP Ml \ \l\l M H NSIN 111! DEFENSIV] I M IX)RSOF rHE BLOOD 515 

case are shown in A. Figure 247; and it will be noted thai he has 
\u\ extensive periodontoclasia. His age is about forty-five. 
He has never had any of the rheumatic gr< up disturbances, nor 
have the members of his family. He is, accordingly, a typical 
illustration from the family history, his own history, and the 
local dental pathology, of the group with a high defense or absent 
susc< ptibility. 1 lis case number is entered as 1 115. 

1 he < ther patient i No. 1 1 1 I pr< sents with symptoms of mild 
heart involvement, nervous exhaustion, and some neuritis. The 
roentgenograms of her teeth are shown in B of Figure 217. It 
will be noted that she has little tendency to gingival recession. 
However, she is young, her age being seventeen. She has several 
pulpless teeth, and notwithstanding a considerable quantity of 
pulp chamber unfilled, there is net extensive absorption of 
alveolar bene. In Chapter 43 I have shown the picture of the 
heart of a rabbit, inoculated with a culture from one of her teeth, 
having both endocarditis and myocarditis. This patient's father 
has had sericus similar involvements, and his case is reported in 
Chapter 22. 

I have, accordingly, undertaken to compare the defensive 
efficiencies of both of these bloods for combating streptococcal 
infection taken from dental source. The result is most striking 
and really remarkable, as shown in Figure 248, which shows two 
rows of Petri dishes, four for each of these two patients. The top 
two, marked A, are Petri dishes containing an agar culture me- 
dium suitable for growing streptococcus, planted with approxi- 
mately one thousand streptococci. These are the controls. The 
other Petri dishes had the same quantity ot the same kind of 
culture medium — namely, 15 cc. — and the same quantity of live 
organisms in each case except as follows: In B, before placing 
the thousand organisms in the Petri dishes they were subjected 
for ten minutes to contact with one- fourth of a cubic centimeter 
of the blood of one of each of these two patients. The germs and 
blood were then put into the Petri dishes which contained fifteen 
cubic centimeters, and as the germs were carried in approximately 
one-thousandth of a cubic centimeter of fluid, the additional 
fluid added to the Petri dishes in B was insignificantly more than 
in A, and the additional nutrient material only that quantity in a 
quarter of a cubic centimeter of blood. 

It will readily be seen that Patient 1414, classified as an in- 
herited susceptibility, did not furnish a blood capable of destroy- 







Figure 248. Comparison of bactericidal capacity of bloods of two patients presenting same hour. 
Case No. 1414 has low defense with heart involvement; Case No. 1415. with high defense and 
normal. (See dental conditions in Figure 247.) 

516 



CHAP. XL] VARIATIONS IN THE DEFENSIVE FAC ["ORSl >F rHE BLOOD 517 

ing a very large number or proportion of the approximately one 
thousand organisms; but in strong contrast with this, the patient 

with the absent susceptibility, Case No. 1 llo, was able to destroy 
a large portion of the one thousand organisms with even that 
small quantity of blood in the' remarkably short time of ten 
minutes. This we might take to represent the readily available 
resources of the blood for meeting an invading infection. But, as 
has been shown, the blood has normally a very high reserve 
defensive mechanism stored up in the leucocytes, which is capa- 
ble, when called forth, to take care of very much larger numbers 
of organisms. I have, accordingly, then, endeavored to deter- 
mine the relative capacity of these two individuals as representa- 
tives of their groups, for meeting an overwhelming or large infec- 
tion, by placing in the same quantity of their bloods in vitro a 
given number of dead specimens of the same organism which we 
are using for testing. In C we have the effect on this quantity of 
organisms — namely, one thousand alive — by being placed in the 
blood of one of these two individuals for ten minutes as before, 
where the blood had been vaccinated for twenty minutes preced- 
ing with one hundred dead streptococci of that strain. It will be 
noted that the blood of Patient 1414 did not have the capacity for 
any greater response since more of the organisms of a thousand 
grew out than when the blood was not vaccinated, whereas the 
patient with the high defense, according to our classification by 
other means and by clinical histories, is shown to be correctly 
named, for the addition of these few dead organisms has called 
forth from his blood a chemical reaction which has devitalized 
practically every one of the thousand organisms in the small 
space of time of ten minutes. 

We might assume, then, that Patient 1414, with low defense, 
did not respond because the vaccinating dose was not large 
enough. We, accordingly, made simultaneously with the preced- 
ing test, a determination of the effect of vaccinating for the same 
period — namely, twenty minutes — with one thousand dead 
organisms per one- fourth cc. of blood, in order that for every 
organism that was to be devitalized, one dead organism would be 
placed in the blood as an antigen to call forth that quantity of 
antibody. The blood of the patient with a low defense was not 
capable of responding to a greater degree with this relatively large 
vaccination, for, in fact, her blood destroyed many fewer organisms 
than without the vaccination, and there seemed distinct evidence 



518 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

that the additional toxic effect of the thousand dead organisms 
embarrassed her blood to a marked degree, for when we compare 
the growth in D with that in A, we find her blood had almost lost 
its capacity for destroying bacteria, at least in that unit period of 
time. The patient presented in the other column, No. 1415, has 
been able to destroy almost all of the thousand organisms, but a 
few are growing, indicating that the toxic additive quality was 
sufficiently great to reduce the efficiency appreciably, since there 
was net approximately 100 per cent devitalization of the bacteria, 
as shown in C. We have, therefore, a type of evidence which sub- 
stantiates the deductions in the preceding chapters, and I see no 
other explanation for the conclusion that the group of individuals 
represented as having the capacity for doing what Patient 1415 
has done as compared with what 1414 has done, than that we are 
dealing with potentially two entirely different capacities for 
defensive reaction. 

This illustrates too why the indiscriminate use of vaccines may 
have a very harmful effect in some instances while being distinctly 
helpful in others. Let us suppose that Patient 1414 had had a 
vaccine used in which the dilution and dosage was either of those 
represented, and probably any dilution between them. It would 
be almost certain that the vaccine would do more harm than 
good and that the patient would be made distinctly more ill. 
On the other hand, we readily see that if the patient in the 
second group received a vaccinating dose of either of these 
quantities, or probably any quantity between, his defensive 
mechanisms would be distinctly sharpened. As suggested, 
therefore, this becomes a means for determining in vitro 
those individuals for whom a vaccine may be expected to be 
beneficial and those for whom it will be injurious; and still more, 
by an extended series of these determinations, the particular 
dosage that will be most efficient for that individual can readily 
be estimated. This, therefore, should remove in the future much 
of the indifferent and negative result from vaccine therapy, and, 
as previously stated, we are indebted to Sir Almroth Wright for 
the development of this and much of the bacteriological and 
serological knowledge regarding the blood and its defensive 
mechanisms. The references to his work are very many 
and I have given the principal ones in the bibliography. 



( HAP \1 I \ UlIATIONSIN I ill DEFENSIVE FA< rORSOF Mil BLOOD 519 

SEROPHYTIC MICROORGANISMS. 
PROBl I'M. What an- (In growth factors of microorgan- 
isms of Ha month in juices of living tissues? 

EXPERIMENTAL AND DISCUSSION. 

We naturally think of nil of the tonus of microbrganic life as 
possible invading factors. It seemed wise to determine, if possi- 
ble, to what extent the natural limitations of the various types of 
organisms would prevent their growth in normal tissue juices, 

assuming that dental infections are continually in contact with 
abraded tissue and that various forms of organisms have an 
epportunity to invade the vital structure. Since one of the first 
mechanisms of Nature's defense, when tissue is abraded, is to 
throw out the lymph, it is suggested as important to determine, 
if possible, which of the mcuth organisms will grow in that fluid. 
I have, accordingly, placed sterile absorbent cotton beneath the 
skins of normal animals in order to collect a sufficient quantity of 
this material for experimental purposes. I have also obtained the 
same material by slow suction from the human. This material 
has been infected with mixed organisms of the mcuth, including 
spirochetes, fusiform, long and short rod forms, micrococci, sub- 
tilis, diplccccci, streptococci, and staphylococci. It is of great 
importance to note that almost invariably, so nearly so that it 
may be considered a constant rule, when animals are inoculated 
with mixed cultures, in many of the above varieties the only 
organism that is recovered from the lesions will be of the coccal 
grcup, and in more than 99 per cent of cases in cur studies of ths 
diplcstreptccoccal groups, there being less than 1 per cent staphyl- 
ococcal infection also. It is not surprising, therefore, that when 
the human or animal lymph is inoculated with the mixed infec- 
tion of the mouth, the streptococci and staphylococci grow out 
in the lymph of susceptible species or individuals, particularly the 
former, while the bacillary forms and spirochetes do not multi- 
ply, or at least do not in sufficient quantities to be found in the 
smears or tissue sections. 

This research has been undertaken for two purposes: First, to 
determine what organisms tend to grow most readily in freshly 
extracted lymph arid, second, as a means of comparing the 
lymphs of different animals. The table shown in Figure 249 shows 
a series of rabbits and rats in different conditions. Rabbit 1202 
had sterile absorbent cotton placed beneath the skin for two 
hours, when it was removed and a couple of cubic centimeters of 



520 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 









LYMPH EXPERIMENT 




















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Figure 249. 



lymph expressed into sterile tubes. Dilutions of one to five, one 
to one, and full strength, were tested, as was lymph similarly 
drawn from Rabbit 1222, by inoculation with the mixed flora 
from highly infected gingival pockets. The chart shows three 
different succeeding dates and the type of streptococcus, whether 
positive or negative, and the type of bacillary form, whether 
Gram-positive or negative, which grew out. It will be noted 
that the undiluted lymph from the two rabbits gave no growth in 
twenty-four hours, whereas the dilution of one to five gave a 
slight growth of Gram-positive streptococci and of Gram-positive 
bacilli. The forty -eight hour culture, however, showed 
Gram-positive streptococci in both the undiluted and a Gram- 
negative bacillus in the other. The ten day growth showed a more 
abundant Gram-positive streptococcus and diplococcus, and 
Gram-negative bacilli. The organism, however, which grew 
out in the majority of instances and most profusely, was the Gram- 
positive streptocc ecus. The three rats — shown in the same chart, 



CHAP. XL] VARIATIONS IN THE DEFENSIV] FACTORS OF THE BLOOD 521 
CHANGES IN RATS WITH PLANTED TEETH NORMA] IND DEFICIENCY 





















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Figure 250. 

had lymph removed in the same manner, and it will be noted that 
in general the same condition obtained though the growth was 
exceedingly weak at first. We find ourselves unable to determine 
when an infected lymph has degenerated to a point where it 
ceases to be comparable to normal circulating lymph, and it is 
probable that after twenty-four hours it should be considered 
that its bactericidal properties would be greatly reduced. In the 
study of the rats, however, it will be noted that the second rat 
serum showed a Gram-positive streptococcus in twenty-four 
hours, but it may be significant that this rat was on a deficiency 
diet, as compared with the one preceding which was on normal 
diet. There is also a greater growth at the end of twenty-four 
hours in the Gram-negative bacillary forms in both the rats on 
deficiency diet. 

These and other results suggested the desirability of repeating 
on the rats some of the experiments that had been made on 
rabbits by the implantation method. The table in Figure 250 
shows a series of these results. Teeth were implanted beneath 
the skins of rats, and their weights were taken on succeeding days. 
The results are strikingly different from those which were ob- 
tained by placing similar infected teeth beneath the skins of 
rabbits. It may be argued that a human tooth is a relatively 



522 DENTAL INFECTIONS. ORAL AND SYSTEMIC -RESEARCHES— VOL. I 

large quantity of infection to place beneath the skin of a rabbit, 
the quantity effect, therefore, accounting for the high mortality 
from that operation. If this quantity factor be true of the 
rabbits, it must of necessity be infinitely more true of the rat, 
which is approximately one-tenth the weight of a rabbit. It is 
most interesting to see, however, that in practically every in- 
stance these infected teeth have produced practically no serious 
effects on the rats when they were on normal diets, as estimated 
by their change in weight, for they have gone on gaining quite 
like the controls. The only difference discernible has been that 
they are not so active in their cages, tending to sit quietly in a 
corner, and this is particularly true of those on deficiency diets. 
When we compare, however, those rats that were on a deficiency 
diet, with those on a normal diet, there is a marked difference. 
When an infected tooth is placed beneath the skin of a rabbit, 
the reaction almost immediately resolves itself into one of two 
processes: either there is formed a capsule, highly vascularized 
and which apparently acts as the defensive mechanism built 
about the structure, in which case the rabbit lives, or there is a 
more or less active local degeneration accompanied by very 
definite changes in the ionic calcium of the blood, the alkali 
reserve of the blood, the ratio of polymorphonuclears to lympho- 
cytes, etc. In exceedingly few cases, however, does a rabbit ever 
expel by a local suppurative process the infected tooth so planted. 
On the contrary, however, rats with their higher defenses will 
build an encapsulation about the tooth, break down a gateway 
to the surface in an astonishingly short period, as shown in the 
chart in Figure 250, in which it will be seen those rats on a normal 
diet shown in Group 1, have expelled the tooth in from six to 
thirteen days, with an average of about nine days. The rats on a 
deficiency diet, however, (see Group II) required over forty days 
on an average to expel an infected tooth. In Group III, we have 
undertaken to get data that would enable us to make comparisons 
between rabbits and rats with regard to their defense at the time 
of pregnancy and the effect of such a foreign implantation in that 
condition. The data available are not sufficient for extended 
conclusions. In general, however, pregnant rats did expel in- 
fected teeth about as rapidly as did the rats that were not pregnant. 
In the chapter on overloads I have shown that when rabbits are 
injected with dental cultures during pregnancy, there is a tend- 
ency to abortion or to the death of the fetal forms, with or with- 



CHAP. XL1 VARIATIONS IN THE DEFENSI\ E FA( rORSOF rHE BLOOD 5 

out the expulsion, and with great danger to the life of the mother 
rabbit. Since the period of gestation with rats is so short 
namely, three weeks it is exceedingly difficult to determine 
whether the effect of tooth implantations tended to hasten con- 
finement. The effects are distinctly different, however, on rats 
than on rabbits, since the offspring of pregnant females carrying 
implanted troth seem to be normal and develop as though no such 
overload had been placed upon them, whereas with rabbits, results 
were nearly always fatal to the offspring. They were either still- 
born or lived but a lew hours. A typical illustration of this 
effect is shown in Figure 251, in which will be seen two rats in the 
backs of which infected teeth were planted. One has completely 
expelled the tooth in nine days, and the other in thirteen. In the 
latter, however, the tooth is just in the process of exfoliation. 

SUMMARY AND CONCLUSIONS. 

1. While this study is, as yet, very incomplete, sufficient 
progress has been made to indicate that there is a very great 
difference in the defensive mechanisms of different species of 
animals. From these studies and from determinations made by 
the method presented, it is apparent that the rabbit and rat 
have distinctly different capacities for defensive reactions to 
dental infections. 

2. The bactericidal property of the blood and lymph of rabbits 
was very similar to that of the human, though under normal con- 
ditions apparently not subject to so great variations. 

3. The organism which tends most readily to grew out in the 
lymph and blood serum of humans and of animals, is a Gram- 
positive streptococcus, which corresponds to our studies reported 
in other chapters regarding the organism isolated from involved 
tissues of animals which have been inoculated with mixed cultures 
from human dental sources. 

We see from the above that there is a great variation in the 
bactericidal properties of different bloods, whether of animals or 
humans, and that this quality of high or low defense relates 
directly to our groupings of individuals with or without sys- 
temic involvements from dental and other fecal infections, and 
that the bactericidal quality can express itself in even one 
minute's time to such a marked extent as to destroy a large 
proportion of the organisms exposed to the blood. We would, 
therefore, briefly express this quality in the following conclusion : 



524 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES- VOL. I 




Figure 251. Two rats with teeth planted beneath the skin, one completely ex- 
truded AND THE OTHER NEARLY SO. THEIR HIGH DEFENSE MAKES THIS POSSIBLE. 



CHAP. XL1 VARIATIONS IN THE DEFENSIVE FA< rORSOF rHE BLOOD ! 

There Is a marked difference, which is very readily 

measurable In the bactericidal properties of the 
bloods of individuals of high defense, as compared 
With those of low defense to systemic involvements 
from dental infections. 

When the mixed flora of the oral cavity is planted 
in the normal blood serum or lymph, the varieties 
that grow are almost entirely limited to the strains 
of diplo- and strepto-cocci, with occasional staphyl- 
ococci, with the diplo- and strepto-cocci largely 
predominating. 



CHAPTER XLII. 

METHODS FOR REINFORCING A DEFICIENT 

DEFENSE. 

PROBLEM: Can a temporarily or permanently lew 
defense against the streptococci of dental infections be 
increased or enhanced either temporarily or permanently ? 

EXPERIMENTAL AND DISCUSSION. 

In the preceding chapter we have seen first that there is a 
great variation in the defensive factor of different individuals as 
expressed in the bactericidal property for streptococci of dental 
origin, and also that this quality regularly diminishes in rabbits 
when they have been subjected to implantation of infected teeth. 
The researches there reported also indicate that the defense of an 
individual tends to go up with the removal of chronic dental 
infections. But many of cur patients do not come back readily 
to normal. If a sapling be broken over, it may straighten nearly 
to its original position. If, however, it can be supported, as 
being tied to a stake, it much more rapidly will repair the injured 
timber and probably recover its original strength. Just in pro- 
portion, however, as that sapling may have been held crushed 
over to the ground for a long period of time, or its defensive 
factors injured by any other means, the prospects for a complete 
recovery are rapidly diminished ; and if it should be that the tim- 
ber in question is that of an old tree, the repair may be much less 
vigorous, and the obstacles that will be safely overcome much 
less, than with the young tissue. 

Similarly, many of our patients come to us with overloads that 
have been present for so long a time that, even though they are 
removed, the defense is very greatly lowered. In many instances 
the overload is one that cannot be reached or removed, and it 
therefore cannot be subtracted. In still others the overload con- 
sists of an inherited deficiency in the mechanisms of defense, for 
we have seen in the preceding chapter that the individuals con- 
stituting our first group in susceptibility — namely, those with 
absent susceptibility — have by inheritance a high defense, and 
they show an unusually high bactericidal property of the blood. 

526 



CHAP Mil METHODS FOR REINFORCING V DEFICIEN1 DEFENS1 

In the second group those with an acquired susceptibility 
while in that state we find that they have a lowered defense 
belov their normal at other times, but that they tend to come 
back to their normal with removal of overloads. In other words, 
the bactericidal property of their blood is temporarily depressed 
by their overloads, one of which overloads is very often a dental 
infection. The third group those with an inherited suscepti- 
bility always have an abnormally low defense against strepto- 
coccal infections; and their normal, which is poor at best, tends 
readily to be still more depressed with overloads. They are in a 
state in which the normal unstimulated defense of the blood is 
not adequate to protect them against streptococcal and staphyl- 
ococcal invasions. In the recurring active combats with this 
type of infection, as any of the rheumatic group lesions, they 
whip themselves up to a defensive reaction adequate to make 
them temporarily relieved. They are, however, dependent upon 
this secondary defensive mechanism which must be called into 
play frequently and vigorously, and, accordingly, they have 
what they call attacks of their disturbance which are largely 
records of remissions and exacerbations. 

When, in any individual the normal defensive mechanism is 
not adequate and the infection continues to develop and increase 
in quantity, the very increase, which endangers the hest, is the 
mechanism which sets in motion the defensive machinery consti- 
tuting the secondary defensive systems of the patients. These 
secondary defenses are largely in the blood and tissue cells of the 
body, probably mostly in the leucocytes of the blood. For years 
as we have studied these patients with their chronically low- 
defenses, we have realized that the desideratum in their behalf 
was to find seme reinforcement which could be brought to their 
aid to supplement their defensive systems. We readily visualize 
how the antitoxin for the diphtheria toxin is developed by the 
horse and can be readily transferred from the horse's blood 
serum to that of the patient, with the result that a sufficient 
reinforcement is added to turn completely the tide of the events; 
and the individual whose death was certain or life despaired of, 
because of his losing the fight with that organism, finds the table 
turned, and thanks to the defensive substances contributed by 
the horse, the patient is new able to make a winning fight and the 
organisms are annihilated from his system or rendered so in- 
noxious to him that the body ignores them, in which case he may 
beccme a carrier. 



528 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

But the toxin developed by the diphtheria bacillus is an exo- 
toxin, and the streptococci and diplococci with which we are con- 
cerned develop largely endotoxins, and it is a very different 
matter to produce outside the body of the host a substance which 
will be bactericidal or antitoxic of such a degree as to make a 
comparable reinforcement to that made by the diphtheria anti- 
toxin. Indeed, we seem to be dependent upon bactericidal sub- 
stances that are generated within the blood and tissues of the 
host for defense against this organism. We, therefore, come 
back continually to the program of using vaccines, preferably 
made from the particular strain of organism that is producing the 
disturbance. I have been using these autogenous vaccines for 
over ten years with very variable results. In many instances the 
vaccines seem to have little, if any, beneficial effect; and, indeed, 
in a few cases they seem to be positively to the patient's dis- 
advantage, while in other cases they seem to work like magic. 
With their use many patients have been seen to make a most 
definite increase in the rapidity of their mastery over the invad- 
ing infection. Several of these are discussed in the chapters on 
systemic involvements; and in several instances where patients 
had been either completely or nearly bedridden for years, they 
have been put back on their feet by changes that have been pro- 
duced, apparently, by the removal of dental focal infections and 
the stimulating of their lowered defenses by use of a vaccine. 

To be more specific, the patient shown in Chapter 64 had been 
bedridden for five years with deforming arthritis. The removal 
of her dental infections produced but little change. The use of 
the vaccine made from those dental infections made so great 
improvement that she was on her feet in five months' time, and 
for two and one-half years she has had no recurrence sufficient to 
put her back in bed. She now does all her housework except the 
laundry. This result was produced with an autogenous vaccine. 

Similarly, the case shown in Chapter 64, who had been bed- 
ridden for four years, completely helpless, has now for several 
years been doing her housework, and continues practically free 
from rheumatic disturbance and progressively improved, ap- 
parently largely the result of the vaccine together with the 
removal of the dental infections. 

Similarly, we might review many cases. Note that while 
many cases have responded beneficially to the use of a vaccine, 
many others have shown no improvement, and this we were able 



CHAP. XI II METHODS FOR REINFORX ING \ DEFK IEN1 DEFENS1 

to determine only after trying and failing. All of (his has sug- 
gested thai ultimately we must find some- substance which may 
be added to the patient's defensive mechanism and thereby help 
him or her directly to combat the infection. Again we are greatly 
indebted to Sir AJmroth Wright for splendid suggestions, for he 
has shown that this process of vaccination of the blood is quite as 
effective in vitro as in vivo] and we have, accordingly, taken that 
suggestion and tested the bloods of the patients presenting for 
diagnosis and means of assistance in the defense against their 
infections. 

In general, we find that while there is a great difference in the 
response of the blood of different individuals, they tend, in 
general, to show a capacity for a greatly enhanced bactericidal 
efficiency of their blood by the introduction first into their blood 
of dead organisms, we now think preferably of the strain for 
which the bactericidal quality is being determined. The differ- 
ence in different patients is so great, that whereas a very few 
dead organisms will suffice to call forth from the blood this 
secondary defensive factor in some cases, in other cases a larger 
quantity of dead organisms are required to do so. There is also 
a very great difference in the extent of this reinforcement for 
secondary defense, as determined b\ r the number of organisms 
that will be killed by a given blood after being vaccinated in 
vitro with varying amounts of dead organisms of the same strain. 
The blood of some patients reaches its maximum efficiency with 
the addition of a very few dead organisms per unit volume, where 
others do not have the maximum efficiency called forth until a 
large number of dead organisms are added; and, similarly, 
whereas some bloods will kill off a large per cent, or nearly all of 
the living organisms, they are aided after being vaccinated, 
whether that quantity of live organisms be five per cubic centi- 
meter or five thousand, or even fifty thousand, some other bloods 
will reach their maximum capacity with a few hundred bacteria. 
In other words, there is a very great difference in the capacity of 
different bloods for reaction, as well as a very great difference in 
the quantity of dead organisms that are required to produce the 
most efficient reaction. 

MEANS FOR COMPARING AND CLASSIFYING THE DEFENSIVE FACTORS 

OF PATIENT'S BLOOD. 

Since, as we have shown, there is a very great variation in the 
bactericidal property of these various patients, when considered 



530 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

individually, and in the groups when considered as such, it 
becomes very desirable to evaluate this defense in comparative 
terms. This has suggested the development of the system of 
uniform observations and determinations to be made on various 
individuals being studied, in order that we may establish, ulti- 
mately, a group of standards which will express the limits that 
may be placed on both an adequate and inadequate defensive 
mechanism. After working out several combinations of tests and 
controls, the one that we are using at the time of this writing as 
being the most simplified to date, is shown in Figure 252. These 
forms are used as the outline for the different determinations and 
the results are checked directly into them, and they lend them- 
selves to modifications when such are desired. The Petri dishes 
are numbered in accordance with the numbers in the column to 
the left, and we soon come to know what tests any given number 
represents. 

All of the study of this phase of our problem — namely, the 
mechanisms of defense of the blood and the means for their 
strengthening — have suggested the necessity for the develop- 
ment of other means than the use of vaccines for the strengthen- 
ing of the defense. To do so has required further knowledge of 
the nature and structure of the substances chiefly instrumental 
in elaborating or generating these defensive factors. Wright has 
shown, as we have repeatedly verified, that the simple proc- 
ess of heating the vaccinated blood before its vaccination with 
the dead organisms entirely inhibits the enhancement of the 
bactericidal property, and this because the leucocytes are devi- 
talized at 48° C. It is therefore possible to determine very 
exactly and directly the amount of the defensive substances al- 
ready in the blood before a reinforcement is drawn from the 
leucocytes. We have, accordingly, demonstrated that in some 
individuals with a chronically low defense the amount of defen- 
sive element present in the blood, without calling forth any 
material from the leucocytes, is exceedingly low, and in son:e 
others we find that the leucocytes tend to contribute this rein- 
forcing immunity with a small amount of stimulation from the 
presence of dead organisms or from toxin, while others require a 
much larger quantity of stimulation. Another and most striking 
feature which we referred to in the preceding chapter is the fact, 
that most blcods of a high defense will develop this secondary 
defense within one minute after the placing of the tooth toxin or 



CHAP. XLI1 METHODS FOR REINFORCING \l>iikll\l DEFENSE 531 



BACTERICIDAL POWER OF BLOOD 





Patient 








i. e No. 








Date 






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Figure 252. 



532 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 

dead bacteria from same, whereas the blood of ether individuals 
will require several minutes (ten to fifteen) to develop the defen- 
sive factors. We have also found that this quality varies through 
considerable range whether a rabbit is normal or has been under 
the strain of a dental infection such as the planting of an infected 
tooth for some days. This latter indicates to us that the presence 
of the dental infection has decreased the capacity of the leu- 
cocytes for reaction, as well as the important data brought out in 
Chapters 19 and 20 showing that the presence of the infection 
reduces the number of leucocytes or produces a leucopenia, 
chiefly a depression of the polymorphonuclears, and also de- 
presses the ionic calcium of the blood. All of this has suggested 
that the whole problem resolves itself very largely, if not quite 
entirely, to one of chemotaxis. 

In this connection we think immediately of the capacity of 
certain drugs to act specifically on certain infections. This is 
quite strikingly illustrated in the effect of quinine on the malaria 
Plasmodium, and of the arsenic compounds, such as salvarsan, on 
the Treponema pallidum. We also think of the action of the 
salicylates which have been used so extensively in the treatment 
of rheumatic affections. I will, accordingly, report here under 
the studies of the mechanisms for the increase of defensive 
mechanisms of blood, some studies we have made with the sali- 
cylates. 

Some years ago I inoculated two groups of rabbits with propor- 
tional amounts of a culture producing acute rheumatism, and 
treated the one group with the sodium salicylates and the other 
without. I was never sufficiently satisfied with the results to 
publish them, since I could not interpret them. The evidence 
indicated that the rabbits receiving the sodium salicylate of the 
doses I was using lived longer, but with reinoculations with the 
same strain, the evidence suggested that a larger percentage of 
the rabbits developed heart lesions. I was never able to deter- 
mine whether the test had important significance since there 
were no data on what should constitute a proper and what an 
overdose of that drug for rabbits, and it would be very clear that 
any overload, such as an overdose, might be distinctly harmful. 

More recently I have had an opportunity to make a different 
type of study directly on the human. A patient with acute 
deforming arthritis presented for our study, reporting that he had 
been getting progressively worse, that the only drug that seemed 



CHAP XI. II METHODS FOR REINFORCING \l>llkli\l DEFENSE 533 

to give him any relief was some form of salicylate, and thai he 
had come to the point that even this had to be taken in such 
large doses that its continuance seriously disturbed his digestion, 
and that his physician was now administering it intravenously 
three times a week. I suggested t<> him that before anything 
was done to disturb dental infections or any other of the factors 
involved, we make studies of the changes in the ionic calcium of 
the blood, if any. accompanying and following the intravenous 
injection of the sodium salicylate. Results were most striking. 
The ionic calcium of his blood at the time was running at ap- 
proximately 7. With each intravenous injection the ionic cal- 
cium of his blood would drop to the neighborhood of 6, and in 
about twenty-four hours it would ascend to 9 or above, and in 
another twenty-four hours would return to about its original 
level. 

Coincidentally, there was a parallel change in his symptoms. 
Within an hour after the intravenous injection of the sodium 
salicylate by his physician, sometimes within thirty minutes, 
(for he came directly, according to our mutual arrangement, 
from one office to the other, a distance of a few blocks,) he de- 
veloped a profound depression amounting to a rather extreme 
negative phase. This usually lasted for about five hours, when 
it gradually disappeared and in its place came a sense of well 
being, great relief from his rheumatic symptoms, and with it a 
displacement of the mental cloud with one of hope and confidence 
and general well being. This latter usually lasted about twelve 
hours, after which he gradually subsided to his old level. The 
history of his case was very similar to that of general clinical 
practice: namely, that the symptoms as pain were greatly re- 
lieved by the use of the salicylates ; that the system needed to be 
pretty well saturated to develop this reaction; that the results 
were relatively transient, requiring quite frequent and continu- 
ous repetition. We have, therefore, in this case an illustration of 
the direct effect of chemotaxis in influencing the defense and also 
indicate one, at least, of the changes occurring in this patient's 
blood. We were not at the time of this series of determinations 
making bactericidal determinations of the blood. This has 
since been done, for he is still suffering and almost an invalid 
with his deforming arthritis. The changes in the ionic calcium 
of this patient's blood, as shown by the various determinations 



534 DENTAL INFECTIONS, ORAL AND SYSTEMIC— RESEARCHES— VOL. I 
IONIC CALCIUM, SODIUM SALICYLATE, AND DIET FACTORS 











Biological Determination 


Chemical Determination 


Date 


Sugar 


Non 
protein 
Nitrogen 


Uric 
Acid 


Calcium 
Ionic 


Calcium 
Ionic and 
Combined 


Calcium 
in Com- 
bination 


Thrombin 


Calcium 


Alkalinity 
Index 


8-17-22 










10.625 










8-24-22 








6.67 


9.81 


2.14 








8-24-22 








7.85 


8.34 


0.49 








8-24-22 








10 00 


11 11 


1 11 








8-26-22 








5 51 












8-28-22 








7.49 












8-28-22 








6.67 












8-28-22 








6.34 


8.76 


2.42 








9- 2-22 








6.67 


9.02 


3.55 








9- 5-22 


105 


47.5 




6.67 


9.33 


2.66 




10.87 




9- 8-22 








6.68 


9.72 


3.04 








9-11-22 








7.27 


8.73 


1.46 








9-13-22 








7.52 


9.52 


2.00 








9-19-22 








7.00 


9.23 


2.23 








9-21-22 








8.10 


9.87 


1.77 








10-18-22 








7.54 


12.08 


4.54 






23.3 


11-23-22 










12.82 




12.68 






12- 8-22 


103 




3.25 




12.10 




13.46 






3- 7-23 


93 


26.5 


2.85 


12.206 


14.34 


2.85 


6.79 






4-19-23 


95 






12.061 


13.34 


1.279 


6 539 







Figure 253. 

are presented in Figure 253. It is important to note that after 
this patient went en a forced milk diet, taking large quantities, 
his ionic calcium has increased from a level at about 8, fre- 
quently being as low as 6 and a fraction, to 12; and while, when 
last seen, he thcught his general condition was somewhat im- 
proved, his actual improvement has been slight; and it is ap- 
parent that the depressed ionic calcium of his blood is not the 
principal factor in his lesion. The bactericidal property of his 
blood is exceedingly low, and the condition strongly suggests that 
if some bactericidal element could be used to reinforce his own 
normal defense, he w r ould make much more rapid progress. He 
has had dental focal infections removed with but little improve- 
ment in his general condition. He has had vaccines used and 
these do not call forth the needed defensive response from his 
blood. He seems quite unable to manufacture the bactericidins 
required for defense against this infection. Since the removal of 
his dental infections, he has been under treatment for chronic 
colitis, which has existed for years and which is undoubtedly con- 
tributing to his general condition, and, indeed, it is not improb- 
able that the infection there is furnishing a toxin which is destroy- 
ing his defensive mechanism or neutralizing its efforts. I have 



CHAP Mil METHODS FOR REINFORCING V DEFICIENT DEFENSE 535 

reviewed tins case in t His. detail to illustrate a condition which 
exists in a very large number of the patients with marked rheu- 
matic susceptibility, and thus emphasize our limitations and 
therein- stress the need tor more intensive effort. 

Another means of approach to this problem has already been 
discussed in the chapter on the Glands of Internal Secretion, and 
it has been instructive to find that whereas a given tooth from 
one of our patients, at the time of this writing has killed thirty- 
three rabbits in an average of four days, the use of injections of 
extract of parathyroid not only seemed to increase the resistance 
of the rabbit, as judged by the length of its life which was ten 
days (only one other rabbit i